Position Summary: 

This is an integrated Case Management and Utilization Review position. The Acute Care Case Manager utilizes industry accepted processes for achieving timely, optimal patient clinical and operational outcomes, coordinated and in cost effective manners. The Acute Case Manager has the responsibility and accountability for assessing, planning, and facilitating individualized continuum care plans for their patients' timely, safe discharge, based on assessed needs and available resources.   The Acute Case Manager also performs Utilization Management throughout the continuum of care in collaboration with other internal and external offices, payors, and providers.  The Acute Care Manager monitors clinical approaches and makes recommendations for alternate levels of care. The Acute Case Manager takes a proactive approach to ensuring the integration of both clinical and operational outcomes through analysis of clinical data against InterQual or other designated criteria including length of stay.

Education, License & Cert: 

RN Bachelor of Science degree in Nursing (BSN) or, a Bachelor of Arts (BA) degree in addition to a degree in Nursing.  A registered nurse with five (5) years relevant experience willing to pursue a BSN or BA degree will be considered.  Must obtain BSN within two (2) years of hire.  Individual consideration may be given to a registered nurse with significant clinical experience who holds a bachelor's degree in a related field.

Experience: 

BSN or BA with a minimum of five (5) years relevant experience who demonstrates leadership and autonomy in nursing practice. a) Utilized critical thinking skills to create and or develop a clinical program b) Demonstrated leadership skills For a licensed degree exception, there must be a significant depth of clinical experience:  five (5) years of experience in an acute care setting with strong case management, utilization review and payer knowledge. Case Management certification is encouraged within one (1) year of eligibility.

Essential Functions: 

1. The Acute Case Manager collaborates to support that the right care is provided to patients in the right setting with a broad spectrum of health and community providers.

a. Works closely with the Medical Director and other members of the healthcare team to provide appropriate medical management and resource utilization employing established approved criteria.

b. Educates providers and other healthcare team members regarding the coordination of care processes for the patient across the continuum of care.

c. Serves a patient advocate in representing the patient's best interests to the providers.

d. Procures insurance authorizations where indicated to ensure appropriate cost‐effective care. 

e. Acts as an institutional advocate by managing care in a cost‐effective manner and communicating with third party payers.

2. Validates authorization/certification process for elective short procedures and urgent inpatient care services in collaboration with physician offices and other hospital departments as appropriate.

a. Screen the appropriate level of care or service for hospital inpatient admissions and short procedures by translating clinical information to Utilization Management requirements using pre‐determined criteria.

b. Documents UR findings in appropriate computer system and screen.

c. Utilizes reports and other mechanisms to identify cases for UR screening and follows procedures for follow up as necessary.

3. Coordinates medical management through ongoing interaction with the patient and family/caregivers, providers, and other health care providers to achieve designated clinical, operational, and financial outcomes.

a. Facilitates clinically appropriate treatment and coordinates flow of services by acting as a focal point for communication for the healthcare team members, patient, provider, and payer.

b. Supports development, integration, and monitoring.  It is understood that this description is not intended to be all inclusive. 

c. Maintains accountability for coordination of care processes for the patient during the acute care phase, and during the transition phase to discharge and outpatient services.

d. Initiates and participates in patient care conferences as appropriate.

e. Completes nursing assessments in the system.  

f. Addresses PRI, Screens, and other referral procedures as needed for continuing needs.

g. Provides leadership for clinical staff regarding complex patient care concerns and/or care of patients who do not achieve expected outcomes

4. Identifies individual patient discharge needs in collaboration with other clinical team members beginning upon initial admission assessment and continued reassessment throughout an episode of care.  Takes the initiative in working with the interdisciplinary health care team and patient/family to identify a treatment regime which streamlines care, reduces or controls cost, and enhances patient outcome.

a. Assists in the implementation of discharge planning as necessary, through concurrent monitoring and reevaluation, to accommodate changes in treatment or progress.  Anticipates changes in treatment and develops contingency plans.

b. Ensures patient's understanding of rights, choices, and consequences.

c. Completes referrals to the appropriate institution, community, or specialized resources.

5. Integrates patient information, clinical/financial/operational data, and evaluates the impact upon the patient, clinical, and financial outcomes.  Identifies opportunities to continue or reduce costs and optimize reimbursement.

a. Identifies cost/clinical outlier patients for intensive case management and facilitates evaluation of alternate care options.

b. Maintains compliance with documentation requirements and guidelines of third‐party payers, regulatory and government agencies.

c. Participates in long‐range planning to meet the needs of high‐risk patients and/or population.

6. Demonstrates leadership skills including effective written and verbal communication, conflict resolution, problem solving and critical thinking, organizational and time management skills and appropriate delegation.

a. Develops and promotes collaborative relationships with other members of the Guthrie Healthcare System Enterprise and community resources, including home health agencies, DME companies, skilled nursing facilities, etc. to explore alternate care options to meet identified patient care needs.

b. Maintains positive and professional relationships with payers that support continued managed care contracts.

c. Articulates the primary objectives of Care Coordination processes to all members of the healthcare leadership team and others, as necessary.

7. Participates in performance improvement and educational activities.

a. Incorporates available current evidence‐based data for clinical management.

b. Demonstrates knowledge of federal, state, and system regulations and aligns practice to comply with such.

c. Serves an educational resource for other members of the healthcare team in regard to changes in reimbursement and /or utilization requirements.

d. Maintains eight (8) hours of continuing education per year.

e. Contributes to Performance Improvement (PI) activities through both individual and aggregate data monitoring.  Initiates and provides leadership for performance improvement activities as appropriate based on outcome data and or problematic issues.

Other Duties: 

1.  Travel for this position is sometimes required. 

2.  Participation in community and employee engagement activities is required.  

3.  It is understood that this description is not intended to be all‐inclusive and that other duties may be assigned as necessary in the performance of this position.

The pay range for this position is $32.98 - $51.46 per hour.