SUMMARY:

The individual in this position is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient�s resources and right to self-determination. The individual in this position has overall responsibility to ensure that care is provided at the appropriate level of care based on medical necessity and assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable re-admissions. This position integrates national standards for case management scope of services including:

• Provides assistance to the Director of Case Management in the management of the department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments
• Utilization Management supporting medical necessity and denial prevention
• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
• Care Coordination by demonstrating efficient throughput while assuring care is sequenced and at the appropriate level of care
• Accountable for compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Provides education to physicians, patients, families and caregivers
• Facilitates educational programs for Case Management Department on community resources use in discharge planning that encourages professional growth
• Provides reports to DCM and hospital leadership as requested

The individual�s responsibilities include the following activities: a) assist the Director in the daily operations of the department b) accurate medical necessity screening and submission for Physician Advisor review, c) transition planning assessment and reassessment, d) implementation or oversight of implementation of the transition plan, e) leading and facilitating multi-disciplinary patient care conferences, f) managing concurrent disputes, g) making appropriate referrals to other departments, h) identification and reporting over and under-utilization, i) communicating with patients and families about the plan of care, j) collaborating with physicians, office staff and ancillary departments, k) leading and facilitating Complex Case Review, l) assuring patient education is completed to support post-acute needs , m) timely complete and concise documentation in Tenet Case Management documentation system, n ) maintenance of accurate patient demographic and insurance information, o) identification and documentation of potentially avoidable days, p) and other duties as assigned.

SKILLS:

Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast paced environment, critical thinking and problem solving skills and computer literacy.

While performing the duties of this job, the employee is regularly required to sit, talk, and hear. The employee is frequently required to use fine motor skill (typing/data entry), and reach with hands and arms. The employee is frequently required to stand; walk; and occasionally stoop, kneel, or crawl. The employee must regularly lift and /or move up to 20 pounds and occasionally lift and/or move up to 50 pounds.

Individual works in a fast paced clinical and office environment.

TRAINING REQUIREMENTS

Must complete Tenet�s InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Attendance at hospital and department orientation is required. Department orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQual�, Transition Management, Utilization Management, and other topics specific to case management.

PRIMARY INFORMATION, TOOLS AND SYSTEMS USED

• Patient data � hospital admission, discharge, transfer system
• Healthcare staff documentation related to patient care
• Regulatory and payor requirements
• Allscripts �, MIDAS & other Care Management Documentation Systems
• McKesson Care Enhance Review Manager (CERMe) InterQual system
• Clinical data interface and secure faxing
• Patient Medical Record including Cerner, Mc Kesson, Meditech, EPIC and HPF
• Hospital specific Clinical Software

POSITION SPECIFIC RESPONSIBILITIES:

• Oversees an adequate number and skill mix of staff over seven days a week to serve the patient population and meet the goals of the department
• Supports and manages staffing requests utilizing the Tenet Case Management staffing recommendations within budgetary guidelines
• Plans and conducts regular departmental meetings with the Director to provide staff updates and ongoing education
• Assists the Director with the implementation of the InterQual Inter-rater Reliability (IRR) Policy to determine initial and yearly competency for all employees performing InterQual reviews
• Ensures new Case Management staff complete department orientation including review of Tenet Case Management and Compliance policies and Documentation training
• Assists the Director of Case Management in the management of the department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments
• Monitors case management processes and staff productivity to ensure medical necessity reviews are completed timely and accurately, payer communications are sent and authorizations or denials documented and followed up, and that transition planning assessments are completed timely.(30% daily, essential)

• Monitors the review process to ensure medical necessity patients to be in the appropriate status and level of care per Tenet policy
• Oversees submission of cases to Physician Advisor to ensure timely referral, follow up and documentation
• Monitors the timely communication clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services
• Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
• Participates in Revenue Cycle meeting, researching disputes, uncovering patterns/trends and educating hospital and medical staff on actionable items
• Implements and monitors physician �peer to peer� review process with payers to resolve denials or downgrades concurrently
• Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
• Utilizes Crimson data to provide timely and meaningful information to the Utilization Management Committee and physician staff for performance improvement.
• Assists the Director in monitoring to ensure that CMS Follow-up Important Message (IM) and HINN letters are delivered and documented per federal regulations and Tenet policy.
• Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
• Identifies and documents Avoidable Days using the data to address opportunities for improvement
• Prevents denials and disputes by communicating with payers and documenting relevant information
• Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements.(20% daily, essential)

• Implements and monitors process to ensure that a transition plan assessment is completed within 24 hours of patient admission to identify and document the anticipated transition plan for patients
• Ensures case management staff use electronic referral request process for patient placements
• Monitors to ensure that patient preference & choice is documented per CMS regulations and Tenet policy
• Monitors to ensure case management staff document in the Tenet Case Management documentation system to communicating information through clear, complete and concise documentation
• Ensures compliance that Case Management Staff are completing comprehensive assessments within 24 hours of patient admission to identify and document the anticipated transition plan for patients
• Integrates key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan
• Identifies patients at risk for readmission and applies appropriate intervention including risk assessment and referral to Social Work and/or Complex Case Review
• May delegate the implementation of the transition plan to LVN/LPN or Assistant staff and follows up to ensure the transition plan is completed timely and accurately
• Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers
• Ensures all Final Discharge Disposition Form are completed for Medicare beneficiaries per Tenet policy
• Accountable to identify and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes documentation in the Tenet Case Management documentation system to communicating information through clear, complete and concise documentation (20% daily, essential)

• Assists the Director in working with Nursing and hospital leadership to ensure Patient Care Conferences and Complex Case Review processes are in place to promote timely and appropriate throughput
• May participates in daily bed management meeting to support timely and effective patient placement and transfer within the hospital
• Monitors to ensures that patients have a plan of care that is clinically appropriate, consistent with patient preference & choice and available resources
• Monitors to ensures consults, testing and procedures are sequenced to support clinical needs with timely and efficient care delivery
• Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
• Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical outcomes
• Ensures the plan of care is clinically appropriate, consistent with patient preference & choice and available resources(10% daily, essential)

• Ensures and provides education to patients, physicians and the healthcare team relevant to the
• Effective progression of care,
• Appropriate level of care, and
• Safe and timely patient transition
• Provides patient and healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options
• Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge
• Provides in-service education to Case Management Department on community resources
• As team leader of discharge planning unit provides guidance and monitoring of activities of discharge planning unit(10% daily, essential)

• Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
• Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies
• Operates within the RN scope of practice as defined by state licensing regulations
• Remains current with Tenet Case Management practices (10% daily, essential)

The metrics below provide an indication of the effectiveness of the individual in this role and may be used for evaluative purposes. The list below is not meant to be exhaustive; other relevant metrics may exist.

• InterQual reviews completed accurately and timely
• Observation length of stay
• Excess Days/ALOS
• Clinical disputes - incidence and dollars
• Clinical Reviews & Authorizations
• Avoidable days
• Resource Utilization
• Position documentation and productivity

SUPERVISORY RESPONSIBILITIES:

Oversees staff assigned to Case Management Department, including, but not limited to, RN and LVN/LPN Case Managers, Social Workers, Case Manager Assistants, Authorization coordinators, and Discharge Planners.