The UM Case Manager-RN is accountable for coordinating, developing, executing, monitoring and evaluating all Case Management activities. Case Management activities encompass: utilization review, resource management, coordination of care, and transition/discharge planning, across the episode or continuum of care. Works in collaborative practice with the physician and other members of the health care team to meet patient-specific and age-related patient needs, linking cost resource management and quality to patient care. Completes established competencies for the position within designated introductory period. Other related duties as assigned.
• Supports the Collaborative Care Management Model as a working partner with physicians, social workers, pharmacists and other professional staff. • Demonstrates proficiency in the application of National clinical case review criteria and appropriate levels of care across the care continuum for managing complex cases and related episodic care events. • Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively. • Demonstrates an understanding of funding resources, services and clinical standards and outcomes. • Demonstrates knowledge of case management standards of practice and processes including identification and assessment, planning, interventions and evaluation. • Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement • RN Provides guidance to LVN Case Managers on complex care team regarding daily issues and complex case information to identify barriers, develop action plans, and program modification for change. • Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals. • Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address utilization/resource and progression of care issues. Assists in developing and implement an improvement plan to address issues. • Develop discharge plan in coordination with and act as a resource to the hospital Care Manager and Discharge Planner. • Implement discharge plan to prevent avoidable days or delays in discharge. • Transition patient to next level of care in coordination with hospital Discharge Planner. • Send discharge letter to PCP. • Pre-certify and recertify appropriate post-acute care. • Identify and refer complex risk members to case management. • Complete documentation completely and accurately in accordance with: (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements. • Identify documents and refer cases to the UM Team Leader for medical review when services do not meet medical necessity criteria and/or appropriate level of care. • Identify and refer cases to the UM Team Leader for potential quality indicators. • Maintains objectivity in decision making, utilizing facts to support decisions. • Supports the mission statement, policies and procedures of the organization. • Assists in eliminating boundaries to achieve integrated, efficient and quality service • Achieves ongoing compliance with all regulatory agencies • Serves as a resource to employees and customers as demonstrated by visibility and knowledge of issues. • Reviews and adheres to department policies and the Utilization Management Plan and Case Management program specific requirements. • Completes interdepartmental education • Accurately applies decision support criteria • Utilizes resources efficiently and effectively • Maintains safe environment • Participates in Performance Improvement activities
MINIMUM EDUCATION: • Graduate of an accredited School of Nursing
PREFERRED EDUCATION: • Bachelor’s or Associate Degree in Nursing. • May substitute experience for degree.
MINIMUM EXPERIENCE: • 3 years' Utilization Management and/or case management experience in an acute or post-acute provider plus health plan other managed care company experience. • Strong working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etc.
PREFERRED EXPERIENCE: • 3 years’ experience in Utilization Review, Discharge Planning and Medical Case Management in a hospital or post-acute care setting. • Strong analytical and organizational skills. • Working knowledge and ability to apply professional standards of practice in work environment. • Knowledge of specific regulatory, managed care requirements.
REQUIRED CERTIFICATIONS/LICENSURE: • Possession of current, unrestricted Texas State licensure for Registered Nurse
PREFERRED CERTIFICATIONS/LICENSURE: • Certified in Case Management or equivalent URAC Recognized Case Management certification. Must obtain within 18 months of employment or transfer into position. • BLS-Obtained through approved American Heart Association Training Center or the Military Training Network (CPR)
North Texas Specialty Physicians, an independent physician association, exists to support the success of the more than 900 primary care and specialty physicians. NTSP provides the business services, analytics and clinical support tools that enable member physicians to maximize performance and deliver superior care to more than 15,000 patients every day.Since 1995, our physician-led organization ha...s engaged the most experienced doctors who want to work with like-minded professionals to use their accumulated knowledge to identify and implement proven practices, successfully manage risk, efficiently share information, and effectively deliver cost-effective, patient-centered care. We promote collaboration, communication, and coordination with processes, systems and technologies that leverage the strengths of the entire network. Our utilization management, case management and disease management services, and in-house clinical consultants, help physicians provide targeted care plans.