Summary:

The Access Case Manager evaluates the medical necessity for admission status. Assesses for transition Planning, and other measures for safe discharge to appropriate level of Care. Coordinates post hospital care when necessary

Essential Functions:

1. Initial patient screening

Identifies high risk patients through rounding and referrals from ED and admitting physicians, surgical services, nurses, hospitalists, ED patients and families, and other mechanisms as appropriate.
Uses ED tracking system, medical record, and demographic information to identify patients needing CM intervention

- Identify patients with frequent ED visits

- Identify patient returning to ED within 2 - 3 days

Document according to policy

2. Utilization review

Screens all patients who meet medical necessity
Works with the admitting physician and admissions to ensure admission to the appropriate status (ie: inpatient, observation, outpatient in a bed), and level of care (ICU, telemetry, etc.) using InterQual or approved criteria.
Educates community based and ED physicians and staff to understand admission status and appropriate patient placement and other regulatory requirements.
Reviews surgical schedules to ensure appropriate status for surgical patients.
Reviews all transfers-in for appropriateness of admission and intervenes as necessary.
Escalates to physician advisor when unable to resolve issues with the attending physician, according to policy and timeframes established.
Preadmission hospital issued notice of non-coverage (HINN) for Medicare patients per physician advisor determination and Medicare guidelines, when medical necessity criteria are not met.
Documents according to policy.
Case Managers who provide care to Joint Replacement patients will receive 1 hour of ortho/joint replacement specific education yearly.

3. Care coordination and patient flow

Initiates the Care Coordination Assessment for select patients.
Facilitates communication and information to all stakeholders.

OTHER RESPONSIBILITIES: As assigned

SUPERVISORY RESPONSIBILITIES: None.

EDUCATION, KNOWLEDGE, SKILLS, ABILITIES AND EXPERIENCE:

Organization, analytical, writing, and interpersonal skills.
Dependable, self-directed, and pleasant.
Critical thinking, problem solving and deductive reasoning skills.
Recent hospital experience preferably ICU, CCU, or strong minimum 3 years Med/Surg. Experience.
Knowledge of Pathophysiology and Disease Process.
Knowledge of Medicare, Medicaid, and Managed Care Health Plans.
Experience in Hospital Case Management preferred.

LICENSES AND CERTIFICATIONS:

Associate degree Nursing required.
Bachelor’s degree in nursing preferred
ACMA, CCM Preferred.
Current American Heart Association BLS required.

AGE OF POPULATION SERVED:

Newborn Infant/Pediatric Adolescent Adult Geriatric All No Patient Care

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