Nurse Case Manager

Westerlo, NY, United States

Department/Unit:

Case Management/Social Work

Work Shift:

Day (United States of America)

Position Title: Nurse Case Manager
Department: Case Management/Social Work
Reports to: Case Management Manager
Job Grade: 27
The Position
The Case Manager is accountable to facilitate the interdisciplinary team to plan, coordinate,
implement and evaluate patient care for assigned service line across the continuum of care. The Case
Manager works proactively with the Quality Improvement Teams, patient care standards, Social
Work, and utilization management to coordinate the appropriate use of resources to achieve
maximum clinical and financial outcomes. The Case Manager participates in maintaining quality care
and performance improvement through leadership, problem solving, decision making, and outcome
measurement. The Case Manager functions as a resource for the health care team, community,
patient/significant others/family and payers by functioning as a clinician, consultant, advocate and
educator for assigned service.
Principal Position Responsibilities
1. Coordination of Care
a. Assists the admission MD and or designated physician and the interdisciplinary teams in
assuring coordination of care across the continuum of care in the hospital pre and post-op.
b. Proactively monitor patients' clinical process through /patient care standards and
evidence based guidelines to ensure timely, appropriate interventions that achieve
optimal patient outcomes within appropriate LOS and financial constraints.
c. Provides collaborative care management with the primary nurse in assessing for
discharge planning needs, coordinating appropriate resources and evaluating
effectiveness of the discharge plan. The discharge planning process needs to begin on
admission.
d. Collaborates with the health care team and appropriate department in the management
of care across the continuum of care, including pre-admission, discharge, post-discharge,
planning length of stay, and utilization of resources.
e. Utilizes own special body of knowledge and evidence based guidelines to provide
leadership and guidance to the health care team in formulating an individualized
multidisciplinary plan of care to include: pre hospitalization, acute hospital care, discharge
education, transition to home and use of community resources.
f. Facilitates and participates in health care team care conference for patients with complex
problems.
g. Facilitates patient and family education and the discharge process to promote continuity
of care and optimal patient outcomes.
h. Demonstrates experience in the referral process and use of community resources.
2. Utilization Review
a. Reviews data from admission screening to clarify admission diagnosis, establish
appropriate length of stay, and identify any potential outliers and determine
appropriateness of admission based on institutional standards and evidence based
guidelines.
b. Contacts payer source to confirm/negotiate benefits and provide concurrent reviews.
Updated 1/2021
c. Identifies capitated patients to determine appropriate utilization of series and coordinates
post hospital care using defined standards.
d. Identifies high-risk patients based on clinical and financial criteria for collaboration with
patient financial services to problem-solve available resources.
e. Ensures that appropriate medical/legal documentation is contained in patient's records.
f. Complies with regulations established by third party payers including but not limited to
notices of non-coverage reinstatement and continued stay.
g. Follows department UM guidelines.
3. Quality Improvement
a. Collaborates with the health care team in implementing strategies to reduce length of
stay/resource consumption to optimize patient health status for an assigned service
patient.
b. Assesses educational needs and provides learning opportunities for health care
professionals relevant to particular cases and selected patient care groups.
c. Demonstrates creativity and critical thinking ability in the development of programs or
projects.
d. Works with quality improvement team for continuous improvement of patient care
outcomes while increasing quality and decreasing cost.
e. Ensure that communication and transmission of documentation occurs with community
agencies.
4. Measurement
a. Collaborates with case management leadership to compile and report aggregate
variances and data for specific patient care services.
b. Communicates and analyzes aggregate variances with members of the health care team
and develops strategies for variance reduction.
A. Mission, Core Values and Service Excellence
1. Contributes to the creation of a compassionate and caring environment for
patients, families, and colleagues through displays of kindness and active listening.
Recognizes and appreciates that each employee’s work is valuable and
contributes to the success of the Mission.
2. Demonstrates excellence in daily work. Willing to actively participate in
performance and quality improvement activities and to work towards enhancing
customer/patient satisfaction.
3. Exhibits positive service excellence skills to patients, visitors, and coworkers by
greeting others in a friendly manner, keeping customers/patients/colleagues
informed about progress, delays, and changes.
4. Demonstrates effective teamwork by interacting in a positive manner with
colleagues and creating a collaborative work environment. Initiates open
communication, conveys positive intent, offers assistance.
5. Contributes to a safe and secure environment for patients, visitors, colleagues by
following established procedures and protocols.
6. Demonstrates stewardship by thoughtful and responsible use of resources including
maintaining a clean and hospitable environment, starting work on time, displaying
a consciousness regarding costs, supplies and department finances.
7. Demonstrates respect for individual differences of each person by acknowledging
the essence of each person, appreciating, and responding to unique, spiritual,
personal, and cultural backgrounds of patients, families, and colleagues.
Updated 1/2021
Qualifications and Ideal Characteristics
1. Registered nurse with a current license in NY State.
2. Bachelor's degree preferred.
3. Minimum of three years clinical experience in an assigned service. Acute care
nursing and case management experience preferred.
4. Recent experience in case management, utilization management and/or
discharge planning/home care in a high volume, acute care hospital preferred.
PRI and Case Management certification preferred.
5. Demonstrates effective communication, facilitation, and organizational skills.
6. Assertive and creative in problem solving, critical thinking skills, systems
planning and patient care management.
7. Self-directed with the ability to adapt in a changing environment.
8. Basic knowledge of computer systems with skills applicable to utilization review
process.
Physical Demands:
The physical demands described here are representative of those that must be met by an employee
to successfully perform the essential functions of this job.
While performing the duties of this job, the employee is regularly required to stand, walk, use hands
to probe, handle, or feel objects, tools, or controls, reach with hands and arms, and speak and hear.
The employee is occasionally required to sit and stoop, kneel, or crouch.
The employee must regularly lift and/or move up to 50 pounds. Specific vision abilities required by
this job include close vision, distance vision, peripheral vision, depth perception, and the ability to
adjust focus.
Work Environment:
The work environment characteristics described here are representative of those an employee
encounters while performing the essential functions of this job. While performing the duties of this job,
the employee may be subject to infectious materials and chemicals (see unit specific MSDS
information).
The noise level in the work environment is usually moderate.
This job requires as an essential function that the majority of the time the employee be physically onsite as the work cannot be done from a remote location.
Other Requirements:
All job requirements listed indicate the minimum level of knowledge, skills, and/or ability deemed
necessary to perform the job proficiently. This job description is not to be construed as an
exhaustive statement of duties, responsibilities, or requirements. Employees will be required to
perform any other job‐related instructions given by their supervisor subject to reasonable
accommodations.

The Case Manager is accountable to facilitate the interdisciplinary team to plan, coordinate, implement and evaluate patient care for assigned service line across the continuum of care. The Case Manager works proactively with the Quality Improvement Teams, patient care standards, Social Work, and utilization management to coordinate the appropriate use of resources to achieve maximum clinical and financial outcomes. The Case Manager participates in maintaining quality care and performance improvement through leadership, problem solving, decision making, and outcome measurement. The Case Manager functions as a resource for the health care team, community, patient/significant others/family and payers by functioning as a clinician, consultant, advocate and educator for assigned service.

Principal Position Responsibilities

1. Coordination of Care

a. Assists the admission MD and or designated physician and the interdisciplinary teams in assuring coordination of care across the continuum of care in the hospital pre and post-op.

b. Proactively monitor patients' clinical process through /patient care standards and evidence-based guidelines to ensure timely, appropriate interventions that achieve optimal patient outcomes within appropriate LOS and financial constraints.

c. Provides collaborative care management with the primary nurse in assessing for discharge planning needs, coordinating appropriate resources and evaluating effectiveness of the discharge plan. The discharge planning process needs to begin on admission.

d. Collaborates with the health care team and appropriate department in the management of care across the continuum of care, including pre-admission, discharge, post-discharge, planning length of stay, and utilization of resources.

e. Utilizes own special body of knowledge and evidence based guidelines to provide leadership and guidance to the health care team in formulating an individualized multidisciplinary plan of care to include: pre hospitalization, acute hospital care, discharge education, transition to home and use of community resources.

f. Facilitates and participates in health care team care conference for patients with complex problems.

g. Facilitates patient and family education and the discharge process to promote continuity of care and optimal patient outcomes.

h. Demonstrates experience in the referral process and use of community resources.

2. Utilization Review

a. Reviews data from admission screening to clarify admission diagnosis, establish appropriate length of stay, and identify any potential outliers and determine appropriateness of admission based on institutional standards and evidence based guidelines.

b. Contacts payer source to confirm/negotiate benefits and provide concurrent reviews.

c. Identifies capitated patients to determine appropriate utilization of series and coordinates post hospital care using defined standards.

d. Identifies high-risk patients based on clinical and financial criteria for collaboration with patient financial services to problem-solve available resources.

e. Ensures that appropriate medical/legal documentation is contained in patient's records.

f. Complies with regulations established by third party payers including but not limited to notices of non-coverage reinstatement and continued stay.

g. Follows department UM guidelines.

3. Quality Improvement

a. Collaborates with the health care team in implementing strategies to reduce length of stay/resource consumption to optimize patient health status for an assigned service patient.

b. Assesses educational needs and provides learning opportunities for health care professionals relevant to particular cases and selected patient care groups.

c. Demonstrates creativity and critical thinking ability in the development of programs or projects.

d. Works with quality improvement team for continuous improvement of patient care outcomes while increasing quality and decreasing cost.

e. Ensure that communication and transmission of documentation occurs with community agencies.

4. Measurement

a. Collaborates with case management leadership to compile and report aggregate variances and data for specific patient care services.

b. Communicates and analyzes aggregate variances with members of the health care team and develops strategies for variance reduction.

Qualifications and Ideal Characteristics

1. Registered nurse with a current license.

2. Bachelor's degree required preferred Master’s degree preferred.

3. Minimum of three years clinical experience in an assigned service. Acute care nursing experience preferred.

4. Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI and Case Management certification preferred.

5. Demonstrates effective communication, facilitation, and organizational skills.

6. Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management.

7. Self-directed with the ability to adapt in a changing environment.

8. Basic knowledge of computer systems with skills applicable to utilization review process.

Mission, Core Values and Service Excellence

1. Contributes to the creation of a compassionate and caring environment for patients, families, and colleagues through displays of kindness and active listening. Recognizes and appreciates that each employee’s work is valuable and contributes to the success of the Mission.

2. Dem...