What are the responsibilities and job description for the Case Manager (RN/LPN) position at The Brookshire?
Job Overview:
Purpose of Your Job Position
The primary purpose of this job position is to influence/management the cost effectiveness of treatment and ancillary services through an intimate relationship with therapy and nursing. You will be involved in the care of all managed care patients starting at pre-admission and continuing through payment for services provided. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results.
Job Functions
As Case Manager, you are responsible for monitoring and documenting the cost effectiveness of treatment provided, facilitates and coordinates the admission and discharge process, serves as the resident family advocate and acts as a liaison to insurance and management professionals. No supervisory function.
1. Participate in the admission process including pre-admission assessment, rate negotiations, benefit verification, care needs and reporting.
Personnel Functions
Nursing Care Function
Budget and Planning Functions
Resident Rights
Miscellaneous
Position Requirements
Education
Degree in Nursing, preferred and/or equivalent experience in Healthcare Management.
Experience
Specific Requirements
Working Conditions
EEO/MFDV
Purpose of Your Job Position
The primary purpose of this job position is to influence/management the cost effectiveness of treatment and ancillary services through an intimate relationship with therapy and nursing. You will be involved in the care of all managed care patients starting at pre-admission and continuing through payment for services provided. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results.
Job Functions
As Case Manager, you are responsible for monitoring and documenting the cost effectiveness of treatment provided, facilitates and coordinates the admission and discharge process, serves as the resident family advocate and acts as a liaison to insurance and management professionals. No supervisory function.
Duties and Responsibilities
1. Participate in the admission process including pre-admission assessment, rate negotiations, benefit verification, care needs and reporting.
2. Communicate resident status, change in function and care plan either by phone or written report to payers.
3. Include payer representative in interdisciplinary meeting if requested or deemed necessary to promote payer/provider relationship.
4. Document all payer interactions regarding resident progress, expected outcomes and reporting capabilities including special instructions.
5. Ensures thorough and timely communication with managed care/insurance case managers to coordinate certification and concurrent stay programs.
6. Assist with the completion of the MDS for managed care patients.
7. Negotiate all one-time payer agreements and LOA’s with the assistance of the Executive Director, District Director of Case Management, and Vice President of Managed Care & Professional Services.
8. Coordinate all services for each managed care patient, including in home and outside of the care center.
9. Approves all payer changes affiliated with managed care patients.
10. Reviews all ancillary invoices with Executive Director and Business Office Manager.
11. Key communicator of discharge plans related to managed care patients.
12. Review and challenge documentation before sending to MCO.
13. Maximize benefits by coordination of cost effective care, avoid fragmented care, duplication of services and ensure the appropriate level of care is provided in the most suitable setting.
14. Meet with facility interdisciplinary team to coordinate services to ensure that the resident’s total regimen of care is maintained.
15. Participate in all Medicare and managed care resident interdisciplinary meetings.
16. Perform clinical assessments.
17. Work with team members to ensure discharge-planning goals and objectives are developed and discussed at the interdisciplinary team meetings.
18. Assist in planning the services required in the resident’s discharge plan as necessary.
19. Maintain communication with facility business office and medical records to ensure accurate census and payment of managed care and Medicare residents.
20. Perform random chart reviews to ensure accurate and thorough documentation to support reimbursement of services rendered.
21. Meet with residents, and/or family members, as necessary. Report problem areas to department directors.
22. Agree not to disclose assigned user ID code and password or accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Executive Director.
23. Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator.
24. Report any known or suspected unauthorized attempt to access facility’s information system.
25. Assist with pre admissions evaluation of potential manage care patients, including cost-cut, insurance authorization and patient/insurance education as necessary.
Personnel Functions
Develop and maintain a good rapport with interdepartmental personnel, as well as other departments within the facility to ensure that services can be maintained to meet the needs of the residents.- Make appropriate reports to department supervisors as required or as may be necessary. Follow facility’s established procedures.
- Report known or suspected incidents of fraud to the Executive Director.
- Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines.
Nursing Care Function
- Ensure that appropriate supplies and equipment, etc., are available to meet the needs of assigned residents.
- Participate in the orientation of new resident/family members to the facility.
- Make rounds with physicians as necessary.
- Admit, transfer, and discharge Medicare and managed care residents as required.
Budget and Planning Functions
- Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
Resident Rights
- Maintain the confidentiality of all resident care information. Report known or suspected incidents of unauthorized disclosure of such information.
- Review complaints and grievances made by the resident and make a written/oral report to the nursing manager indicating what action(s) were taken to resolve the complaint or grievance. Follow the facility’s established procedures.
- Report all allegations of resident abuse and/or misappropriation of resident property.
Miscellaneous
- Provide data to the Quality Assurance Committee as requested.
- Participate in facility committees as required.
- Coordinate cost effective, quality care assuring that cost containment does not take precedence over quality and safety.
- Participate in the development, maintenance, and implementation of the facility’s quality assurance program.
Position Requirements
Education
Degree in Nursing, preferred and/or equivalent experience in Healthcare Management.
Experience
Must have, as a minimum, three (3) year’s experience in a hospital, nursing care facility, or other related health care facility.- Must have training in rehabilitative and restorative nursing practices.
- Must have a working knowledge of managed care rules, regulations, and guidelines.
- Must have knowledge of managed care and PPS systems.
Specific Requirements
Must possess a demonstrated knowledge of care management; managed care, Medicare, utilization management practices, insurance benefits and cost management strategies.- Must possess knowledge of and demonstrated competency in ensuring compliance with Medicare and third party reimbursement, criteria/ levels of care.
- Must have knowledge of and experience with data base applications to enable use of computerized MDS systems.
- Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
- Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to managed care and nursing facilities.
- Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
- Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care.
- Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.
- Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
Working Conditions
Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses’ stations, resident rooms, etc.).- Moves intermittently during working hours.
- Is subject to frequent interruptions.
- Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.
- Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.
- Communicates with medical staff, nursing personnel, and other department directors.
- Works beyond normal working hours and on weekends and holidays when necessary.
- Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.)
- Is involved in community/civic health matters/projects as appropriate.
- Attends and participates in continuing educations programs.
- May be subject to the handling of and exposure to hazardous chemicals.
- Maintains a liaison with the resident, their families, support departments, etc., to adequately plan for the residents’ needs.
EEO/MFDV
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