A. Within 24 hours of admission interview each patient/family for anticipated needs post hospitalization
B. Develop “plan for the day” and “plan for the stay” with providers, patient and nursing staff
C. Lead daily care coordination rounds to update the plan and facilitate implementation.
D. Initiate discharge plan including early referrals to homecare, DME and infusion services
E. Prepare patient/family for discharge
F. In collaboration with SW “partner” follow standard for routine patient/family conference
G. Ensure patient handovers to next level of care; work closely with Care Navigators in clinics, complex care Case Managers, homecare and sub-acute liaisons
H. Support nursing Model of Care by working closely with nursing managers and staff to achieve Patient Family Centered Care goals: respect and dignity, information sharing, participation and collaboration
I. Facilitate increased volume of cases discharged by noon to improve capacity management
J. Collect “avoidable days” information; report findings in care management software, such as Allscripts
K. Participate in venues to reduce barriers to discharge
Principle responsibilities for RN Case Managers staffed in the emergency departments includes:
L. Identify patients in need of Case Management services through case finding and collaboration with multidisciplinary team in the ED
M. Provide clinical and financial pre-admission screening of all unscheduled patients utilizing UMHS clinical standards and financial guidelines while also being in accordance with federal, states and payer guidelines
N. Acts as a patient advocate and communication link with other health care departments and community resources – both internally and externally
O. Ensuring patients not meeting skilled care requirement but unable to return to prior living situation are discharged to appropriate level of care from ED with clear financial information to patients / families
P. RN CM’s working the ED’s during evening and night shift will support all EDs and AMOU. RN CM’s will also support any unanticipated urgent needs in the inpatient areas.
Utilization Review and Utilization Management
A. Conduct clinical review on admission; review every 3 days or as requested by payer
B. Determine patient classification with provider and ensure all patients placed in “ observation” classification are notified; For “inpatient” to “observation” cases, ensure Condition Code 44 billing requirements are met
C. Communicates with third party payers to obtain necessary authorization for reimbursement of services.
D. Obtain anticipated LOS from provider and ensure patient and multi-disciplinary team is aware
E. Refer defined cases for medical secondary review and share findings with providers
F. Provide advice to Revenue Cycle/HIM regarding RAC decision to appeal, denials; input into appeals; share findings with providers
G. Review all cases with readmission within 30 days; report findings in Care Management software such as Allscript
H. Identify opportunities for cost reduction and participate in appropriate utilization management venues
I. Conducts referrals and consultation with Physician Advisor