APPENDIX J

CASE MANAGER–ADMITTING OFFICE
Job Description
 JOB TITLE: Case Manager (Admitting Office)
 DEPARTMENT: Case Management
JOB SUMMARY: The case manager screens all patients referred to the admitting office to determine, through the use of clinical indicators, the patient's severity of illness and the intensity of services required and compares these to the services being requested. The case manager contacts the physician requesting the service to discuss care alternatives when requested services do not meet the clinical indicator requirements.
REPORTS TO: Director of Case Management
 SUPERVISES: Clerical Support Staff

RESPONSIBILITIES:
  1. Utilizes established criteria for potential admissions to determine the following:
    a. Appropriateness of admission
    b. Appropriateness of setting
    c. Patient placement type (i.e., observation status, outpatient)
    d. Discharge planning needs
    e. Care facilitation need
  2. Initiates discussions with attending physician for patients who do not meet appropriateness criteria and for whom alternative care arrangements can be made.
  3. Will refer the patient to admitting personnel once appropriateness of setting and care requirements are met to obtain preauthorization/precertification.
  4. Intervenes with the payer when needed to assist admitting personnel in obtaining authorization.
  5. Initiates discussions with the attending physician if there are anticipated discharge needs apparent at the time of preadmission assessment.
  6. Reviews all same-day admissions before the scheduled day of surgery to ensure that authorization has been appropriately obtained and to determine the need for appropriateness of setting or any discharge planning needs.
  7. Reviews all requests for transfers from other facilities to ensure that the patient's condition necessitates the transfer and provides feedback to the sending facilities regarding determination.
  8. Utilizes an intake assessment form to evaluate patients and families in collaboration with the physician and/or office staff in presurgical testing unit.
  9. Documents clinical information necessary to obtain approval from the payer as indicated in the patient medical record and maintains record until patient arrives at the hospital.
  10. Notifies the inpatient case manager on issues related to the following:
    a. Coverage limitations
    b. Special patient/family circumstances
    c. Potentially avoidable days (i.e., presurgery, preprocedure days)
    d. Other issues, as appropriate
  11. Contacts the patient/family to explore anticipatory discharge planning options, as appropriate, and collaborates with social work as needed.
  12. Documents a case manager "preadmit note" in patient record, including discharge planning discussions held.
  13. Consults with nursing staff and staff in ancillary departments to eliminate barriers to efficient delivery of care.
  14. Refers all potential hospital liabilities/incidents to risk management.
  15. Employs a high degree of skill in all oral and written communications and personal interactions and demonstrates collaborative working relationships.
  16. Uses appropriate resources and methods to resolve conflicts with others.
  17. Meets assigned deadlines and quality standards without reminder from supervisor or others.
  18. Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis.
  19. Maintains absolute adherence to hospital and departmental policies and practices regarding confidentiality and patients' rights.
  20. Demonstrates knowledge and support of the hospital's missions and values.
  21. 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. Leadership experience preferred. Utilization review or discharge planning experienced preferred.