APPENDIX L

CASE MANAGER–COMMUNITY
Job Description
 TITLE: Case Manager (Community)
 DEPARTMENT: Case Management
JOB SUMMARY: The case manager is responsible for facilitating the patient's care process in the outpatient setting. 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, referrals to outside agencies, and use of services across the continuum. Will advise the healthcare team and provide leadership as needed.
REPORTS TO: Director of Case Management
 SUPERVISES: Case Management Support Staff
RESPONSIBILITIES:
  1. Uses high-risk screening criteria to assess patients' level of care needs. Completes this on admission to the outpatient setting and every 6 months, or as needed.
  2. Completes a comprehensive physical, social, and financial assessment of the patient/family to determine priorities in developing a plan of care.
  3. Coordinates the plan of care with all members of the interdisciplinary team.
  4. Identifies patients and families who have complex psychosocial, financial, and/or legal needs and refers those patients to social work.
  5. Interacts with patients and families on an as-needed basis to modify and update the plan of care based on the assessment.
  6. Obtains from third-party payer certification for use of service across the continuum (i.e., home care).
  7. Updates and modifies the interdisciplinary plan of care as needed based on an assessment of the patient's achievement of expected outcomes of care.
  8. Collaborates with patients/families to coordinate community services and appropriate resources that meet the patient's/family's needs and goals.
  9. Discusses with attending physicians and/or physician advisors the appropriateness of resource utilization, consultations, and treatment plan.
  10. Collects data on variances identified in the out-patient setting.
  11. Communicates to risk management all incidents that are potentially compensable events.
  12. Responds to third-party payer requests for concurrent clinical information.
  13. Ensures that chart documentation supports the level of care provided.
  14. Conducts multidisciplinary case conferences (e.g., nursing, house staff, social work) as needed to ensure the following:
    a. Completion and reporting of diagnostic testing
    b. Completion of treatment appropriate to the episode of illness
    c. Modification of the plan to meet the continuing needs of the patient
    d. Communication of relevant issues and third-party payer information to the team
  15. Discusses estimated length of treatment, frequency of outpatient visits, or other care modalities 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. Collaborates in developing, implementing, and evaluating teaching/learning strategies for patient/family in the community.
  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. Identifies, resolves, and eliminates conflicts in the patient treatment plan.
  20. Performs ongoing evaluation of the plan of care to ensure that current and potential complications are identified and to evaluate the effectiveness of interventions.
  21. Ensures that patient appointments are made for follow-up visits.
  22. Communicates with other case managers along the continuum, including acute care, home care, managed care, and long-term care.
  23. Employs a high degree of skill in all oral and written communications and personal interactions.
  24. Uses appropriate resources and methods to resolve conflict 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 policies and practices regarding confidentially and patients' 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 and leadership experience preferred.

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