Inpatient Case Manager at ECHN in Manchester, Connecticut

Posted in Sales 2 days ago.





Job Description:

Job Summary:# Responsible for coordination of daily inpatient services including assessments, treatment planning, monitoring, evaluation, documentation and discharge planning function in accordance with Prospect Medical Group policies, procedure and processes.# Interacts with the Medical Directors and hospitalists on a daily basis to determine necessity of continued stay. Essential Duty###1#-#Percent: #60% # ######### Effectively manage patients either telephonically or onsite during their hospitalization to ensure the appropriate level of care is provided for the patient#s severity of illness. Utilizes the appropriate tests and diagnostics in the right facilities to facilitate the highest level of care in the most efficient manner.# Communicates effectively with facility staff and hospitalist to gather clinical information through verbal and written communications, and provides timely and accurate responses to request information or provide authorization decisions. ######### Interacts with hospitalists and patients daily to evaluate plan of care including discharge planning to determine that patients are receiving quality care and appropriate discharge disposition.# Applies medical knowledge to authorize outpatient services as an alternative to hospitalization when appropriate.# Arranges for transfer to in-network care when appropriate. ######### Updates clinical information in the electronic medical management record system with treatment plan, objectives, results and next steps.# Documents all information accurately. ######### Initiates and continues direct communication with health care providers involved with the care of the member, including the IPA or Hospitals Group if applicable, to obtain complete and accurate information.# Applies appropriate benefits. ######### Anticipates and initiates discharge planning within twenty four hours (24 hours) of admission, completes post discharge call within 24 hours to identify barriers and prevent readmission. Identifies post discharge care needs and refer to the appropriate outpatient programs and/or providers. ######### Utilizes current approved criteria along with clinical experience to make authorization decisions.# Identifies cases not meeting criteria and provides clinical information and rationale to the Medical Director for review and determination. ######### Actively participates in daily rounds with current and accurate clinical information. Prepared to discuss current treatment plans from the Hospitalists or Specialists, plan of care for discharge disposition and continuity of care. ######### Effectively manage an average census of 15-20 patients at any given time. ######### Mandatory After Hours On-Call pager coverage as assigned. Essential Duty###2#-#Percent:##30% ######### Refers cases to the Medical Director as appropriate for review of potential observation status. ######### Identifies and refers cases appropriately for High Risk, Homebound, Hospice/Palliative, SNF, QI and Health Education, per policy, and documents referral in case file. Essential Duty###3###Percent:##10% ######### Identifies and reports under and over utilization of medical services, delays in service by provider or hospital or treatment and quality of care issues to the Medical Director. ######### Actively participates in internal quality and work flow enhancement projects, and other duties, as assigned.# Identifies and reports departmental operational issues and resource needs to the appropriate management personnel. Qualification Requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. This job description reflects management#s assignment of essential functions, it does not prescribe or restrict the tasks that may be assigned.# The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.### Education/Experience:# RN active unrestricted license with 3 # 5 years experience in a medical group or Health Plan setting with strong clinical skills and critical thinking,# At least 4 years of concurrent review experience, preferably in a managed care setting.# Experience with Microsoft Office Word (40 WPM). Knowledge/Skills/Abilities: Recommend but not required, knowledge of NCQA, Cal-Optima, Medicare, Health Plan, DHS and State standards and other regulatory requirements. Recommend but not required knowledge of IDX. Make independent decisions. Knowledge of nationally recognized criteria InterQual, etc. Maintains strong working relations with internal and external customer. Effectively articulates clinical and non-clinical information to persons of all levels. Communicates positively and effectively Maintains member confidence and protects operations by keeping claim information confidential in compliance with HIPPA requirements. 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.## Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. # While performing this job, the employee is regularly required to sit; use hands to finger, handle, and/or feel; and talk and/or hear.# The employee frequently is required to stand and/or walk.# The employee is occasionally required to climb or balance and stoop, kneel, crouch, and/or crawl.# The employee may lift and/or move up to ten-fifteen (10-15) pounds.# Specific vision abilities required by this job include close vision. Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. #