Provides case management services for low-risk patients, including evaluating needs, determining eligibility, and developing client-focused care plans. Coordinates resources and disposition planning to ensure continuity of care and adherence to regulatory guidelines.
Requirements summary
Requires a Bachelor's degree in Nursing or a related field, or a minimum of three years of experience in case management. Candidates must possess strong skills in teamwork, written communication, and relationship management.
Provides case management services to a limited caseload of low-risk patients. Coordinates with patients and their caregivers to evaluate needs, goals, and current services. Determines initial eligibility, benefits, and education for all admissions, assessing medical necessity and required level of care to inform physicians. Enters authorization data. Partners in the development of a client-focused case management plan in collaboration with healthcare team, patient, and caregivers that is consistent with regulatory, accreditation, and regional guidelines. Supports patients with gaining access to care based on their needs, making referrals as appropriate. Coordinates resources and services to assure continuity and quality of care. Attends case management rounds with clinician and supports the review of authorizations and diagnoses as needed. Assesses patient progress toward treatment milestones and care plan goals. Assists with identifying barriers to achieving goals and ensures that they are discussed with the patient and care team thoroughly. Assists with verifying that all services remain consistent with established guidelines and standards. Documents the patients case in all medical files. Reviews benefits/services available to patients, caregivers, and other members of the community and assists with problem solving identified concerns. Identifies patients ready for disposition planning activities. Develops and communicates a comprehensive disposition plan in collaboration with the patient, caregivers, physician, nurses, social services, and other healthcare providers and agencies. Obtains authorizations as needed for patient services. Attends professional seminars, workshops, and approved educational programs and workshops. Monitors operational team data and key metrics applied to own work. Makes suggestions for change or improvement as needed. Ensures adherence to policies to meet regulatory requirements.
Essential Responsibilities
Pursues effective relationships with others by sharing resources, information, and knowledge with coworkers and members. Listens to, addresses, and seeks performance feedback. Pursues self-development; acknowledges strengths and weaknesses based on career goals and takes appropriate development action to leverage / improve them. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work. Assesses and responds to the needs of others to support a business outcome. Completes work assignments by applying up-to-date knowledge in subject area to meet deadlines; follows procedures and policies, and applies data and resources to support projects or initiatives with limited guidance and/or sponsorship. Collaborates with others to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities.
Assists in providing services related to the initial case assessment by: coordinating with patients and their families to evaluate needs, goals, and current services with day-to-day supervision; determining initial eligibility, benefits, and education for all admissions with day-to-day supervision; entering authorization data (e.g., authorization data regarding admitting/principle diagnoses, bed type(s), and disposition data for accuracy, after visit summary) with general guidance; supporting others in exploring options to assure that quality, cost-efficient care is provided; and leveraging working knowledge to assess medical necessity for hospital admission and required level of care to inform physicians.
Assists in monitoring and evaluating plan of care by: coordinating resources and services to assure continuity and quality of care; supporting the review and updating of authorizations, attending case management rounds with clinicians, and reviewing diagnoses as needed; contacting patients periodically to assess progress toward treatment milestones and care plan goals with day-to-day supervision; assisting with identifying barriers to achieving goals and ensuring that they are discussed with the patient and care team thoroughly; assisting with verifying that all services remain consistent with established guidelines and standards; and documenting/updating the patients case in all medical files with minimal guidance.
Assists in providing services related to the case-planning process by: partnering in the development of a client-focused case management plan with treatment goals based on the patients and familys/caregivers needs under limited guidance; collaborating with health-care team, patient, and caregivers to assure plan of care is safe, agreeable, and appropriate with guidance; and validating that the plan is consistent with regulatory, accreditation, and regional guidelines with some guidance. Supports efforts to remain updated on current research, policies, and procedures by: coordinating with others to attend seminars, workshops, and approved educational programs and workshops specific to professional needs; contributing to the implementation of systems, processes, and methods to maintain team knowledge of community resources, with some guidance; analyzing operational team data and key metrics applied to own work with limited guidance; making suggestions for change or improvement as needed with minimal guidance; and learning about and adhering to policies and regulations impacting the teams work with minimal guidance.
Assists in services related to patient disposition by: assisting in identifying patients ready for disposition planning activities under guidance; beginning to develop, evaluate, coordinate, and communicate a comprehensive disposition plan in collaboration with the patient, family, physician, nurses, social services, and other healthcare providers and agencies; and obtaining authorizations/approvals as needed for services for the patient with day-to-day supervision.
Assists in connecting patients with existing services by: supporting patients with gaining access to care based on their needs and integrating or referring them into existing programs/services with minimal guidance; referring patients to outside entities, ambulatory case managers, care managers, social workers, and/or internal/external resources as appropriate with guidance; and gathering and summarizing information for making location-specific adaptations as necessary. Assists others in serving as liaison between internal and external care by: reviewing benefits/services available based on regulations or specific coverage to patients, families, and other members of the community, and assisting with problem solving identified concerns with general supervision; providing case management to a limited caseload of low-risk patients referred to external facilities/agencies with general supervision; learning and applying standard strategies and concepts to propose recommendations in interdisciplinary team meetings with internal and/or external stakeholders with guidance; and leveraging working knowledge of the patients case to act as a resource for physicians, health plan administrators, and contracted vendors.
Minimum Qualifications
Bachelors degree in Nursing or related field OR Minimum three (3) years of experience in case management or a directly related field. Additional Requirements: Knowledge, Skills, and Abilities (KSAs): Integrity; Teamwork; Dependability; Written Communication; Acts with Compassion; Member Service; Relationship Building; Managing Diverse Relationships; Maintain Files and Records; Business Relationship Management; Company Representation
