APPENDIX I

CASE MANAGER–INPATIENT
Job Description
 JOB TITLE: Case Manager (Inpatient)
DEPARTMENT: Case Management
JOB SUMMARY: The case manager is responsible for facilitating the patient's hospitalization from preadmission through discharge. The case manager coordinates with physicians, nurses, social workers, and other health team members to expedite medically appropriate, cost-effective care. The case manager applies clinical expertise and medical appropriateness criteria to resource utilization and discharge planning. Will advise the healthcare team and provide leadership as needed.
REPORTS TO: Director of Case Management
 SUPERVISES: Case Management Support Staff

RESPONSIBILITIES:
  1. Within 24 hours of admission, initiates discharge planning by assessing the patient's needs and documenting the assessment on the interdisciplinary plan of care.
  2. Within 24 hours of admission, identifies patients and families who have complex psychosocial, financial, and legal discharge planning needs and refers those patients to social work.
  3. Ensures that the interdisciplinary care plan and the discharge plan are consistent with the patient's clinical course, continuing care needs, and covered services.
  4. Using established criteria, reviews the following:
    a. Appropriateness of patient's admission
    b. Need for continued stay
    c. Information needed for discharge
  5. Obtains the following from third-party payer:
    a. Certification due to patient status change
    b. Information needed for discharge
  6. Discusses with attending physicians and/or physician advisors the appropriateness of resource utilization, consultations, and treatment plan.
  7. Collects data on variances from quality screening criteria approved by the quality assurance committee. Forwards this data to the quality management department for continued support of the clinical departments.
  8. Communicates to risk management all incidents that are potentially compensable events.
  9. Responds to third-party payer requests for concurrent clinical information.
  10. Issues letters of denial and reinstatement within regulatory timeframe.
  11. Coordinates activities to ensure patient's appeal right under the discharge appeals program.
  12. Ensures that chart documentation supports the need for continued stay.
  13. Completes the Patient Review Instrument (PRI) in a timely manner.
  14. Conducts daily multidisciplinary rounds (e.g., nursing, house staff, social work) on the assigned units, reviews the patient's plan of care, and focuses on the need for continued hospitalization. Coordinates and leads staff as indicated to ensure the following:
    a. Completion and reporting of diagnostic testing
    b. Completion of treatment appropriate for the acute episode of illness
    c. Modification of the plan to meet the continuing care needs of the patient
    d. Communication of relevant issues and third-party payer information to the team
    e. Assignment of appropriate level of care
  15. Discusses estimated length of stay, treatment, and discharge plan with the attending physician, as indicated.
  16. Ensures that all critical elements of the plan of care are communicated to the patient and family and are documented on the interdisciplinary plan of care.
  17. Coordinates discharge teaching. Ensures that teaching is completed by members of the interdisciplinary team.
  18. Consults with physician advisors, nursing staff, and staff in ancillary departments and coordinates the elimination of barriers to efficient delivery of care in the appropriate setting.
  19. Resolves and eliminates conflicts in the patient treatment plan.
  20. Ensures timely completion of all discharge, transfer, and referral forms.
  21. Ensures that discharge prescriptions and discharge orders are written before patient's departure.
  22. Ensures that patient follow-up appointments are made before patient's departure.
  23. Employs a high degree of skill in all oral and written communications and personal interactions.
  24. Uses appropriate resources and methods to resolve conflicts with others.
  25. Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis.
  26. Demonstrates active collaboration with other members of the health team to achieve the Case Management programmatic goals.
  27. Maintains absolute adherence to hospital and departmental polices and practices regarding confidentiality and patient's rights.
  28. Demonstrates knowledge and support of the hospital's mission and values.
  29. Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities.
SKILLS/QUALIFICATIONS: Licensed as a registered nurse. Baccalaureate degree preferred. At least 5 years of clinical experience as a registered nurse. Supervisory skills required. Utilization review or discharge planning experience preferred.

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