DMC Sinai-Grace Hospital is DMC’s largest hospital, offering a comprehensive heart center, cancer care, gerontology, emergency medicine, obstetrics/gynecology and cosmetic services. Sinai-Grace’s joint replacement program features a revolutionary minimally invasive knee and hip replacement surgery that attracts patients from all over the country. Sinai-Grace operates more than 21 outpatient care sites and ambulatory surgery centers throughout Wayne and Oakland Counties and is one of 10 hospitals in the nation to be awarded a Robert Wood Johnson Foundation grant to help set the standards of cardiac care for hospitals and physicians throughout the nation.

Job Description:

The RN Case Manager is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patients resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity and to assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including: Utilization Management supporting medical necessity and denial prevention. Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction. Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care. Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy. Education provided to physicians, patients, families and caregivers.

The individuals responsibilities include the following activities:

a) accurate medical necessity screening and submission for Physician Advisor review,

b) care coordination,

c) transition planning assessment and reassessment,

d) implementation or oversight of implementation of the transition plan,

e) leading and facilitating multi-disciplinary patient care conferences,

f) managing concurrent disputes,

g) making appropriate referrals to other departments,

h ) identifying and referring complex patients to Social Work Services,

i) communicating with patients and families about the plan of care,

j) collaborating with physicians, office staff and ancillary departments,

k) leading and facilitating Complex Case Review,

l) assuring patient education is completed to support post-acute needs ,

m) timely complete and concise documentation in Case Management system,

n ) maintenance of accurate patient demographic and insurance information,

o) identification and documentation of potentially avoidable days,

p) identification and reporting over and underutilization,

q) and other duties as assigned.

POSITION SPECIFIC RESPONSIBILITIES:

Utilization Management: Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management. Assures the patient is in the appropriate status and level of care based on Medical Necessity process and submits case for Secondary Physician review per Tenet policy. Ensures timely communication of clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services . Advocates for the patient and hospital with payers to secure appropriate payment for services rendered. Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes. Identifies and documents Avoidable Days using the data to address opportunities for improvement. Prevents denials and disputes by communicating with payers and documenting relevant information. Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements. (30% daily, essential).

Transition Management: Completes comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan for patients. Integrates key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan. Identifies patients at risk for readmission and applies appropriate intervention including risk assessment and referral to Social Work services and/or Complex Case Review. May delegate the implementation of the transition plan to LVN/LPN or Assistant staff. And follows up to ensure the transition plan is completed timely and accurately. Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers. Provides information to patients to make informed choices when community services per Tenet policy. Completes Final Discharge Disposition Form Assessment for Medicare patients per Tenet policy. Identifies and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes documentation in the Tenet Case Management system to communicating information through clear, complete and concise documentation (30% daily, essential).

Care Coordination: Screens patients for factors that may affect the progression of care and intervenes as needed to promote timely and appropriate throughput. Conducts assessments and stratifies patients at risk for readmission or in need of Case Management services. Ensures the plan of care is clinically appropriate, consistent with patient choice and available resources. Ensures consults, testing and procedures are sequenced to support the patients clinical needs with timely and efficient care delivery. Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care. Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical outcomes (15% daily, essential).

Education: Ensures and provides education to patients, physicians and the healthcare team relevant to the- Effective progression of care, Appropriate level of care, and Safe and timely patient transition. Provides patient and healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options. Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge (15% daily, essential).

Compliance: Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services. Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies. Operates within the LVN/LPN scope of practice as defined by state licensing regulations. Remains current with Tenet Case Management practices (10% daily, essential).

1. Graduate from an accredited school of nursing. Bachelors degree in Nursing or other health-related field, or equivalent combination of education and/or related experience.

2. Two years of acute hospital patient care experience. Acute hospital case management experience preferred.

3. License to practice as a Registered Nurse in the State of Michigan.

4. Accredited Case Manager (ACM) preferred.

5. Must complete Tenets InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Attendance at hospital and department orientation is required. Department orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQual, Transition Management, Utilization Management, and other topics specific to case management.