The best of modern health care technology, plus the best of small town America!
Located in the midst of the beautiful rolling hills and woodlands of Pennsylvania, you don't have to be a native to feel at home here. No matter where your roots, you'll quickly recognize that the staff at Penn Highlands DuBois (PH DuBois) like other residents of the community, will make you feel right at home.
PH DuBois offers residents of west central Pennsylvania a rare combination of technologically advanced health care in a warm, friendly environment. Widely recognized as one of the leading health centers of its kind in the commonwealth, PH DuBois is an oasis of clinical and technical excellence, with a focus on patient-centered care. Its rural setting is just far enough from the hustle of the city life to make it peaceful, but close enough to provide easy access to sought-after urban attractions.
POSITION SUMMARY: The RN Case Manager is a professional who coordinates with the interdisciplinary team, patient/family on complex aspects of the patients' care, medical necessity, insurance reviews and serves as the focal communication point for patients, families, physicians and staff; works closely with the attending physician(s), social workers, nurses, and other members of the team throughout the continuum of care for identified complex inpatients and outpatients; is responsible for preadmission, admission, clinical continued stay, reviews, discharge screening, simple discharge planning, and cost effective outcomes for a caseload of patients; facilitates coordination of an interdisciplinary plan of care to guide patient progress toward achieveing clinical, timely, and cost effective outcomes; collects available and prevents delays and/or clinically significant findings from the medical record to
identify best practices and targeting performance improvement efforts; requires self-direction, motivation, organization, critical thining skills and interpretation of information relating to a wide varity of patient options for discharge planning; requires extensive internal and external contacts with staff, physicians, management, and community resources.
*Complies with PENN HIGHLANDS DUBOIS policies and procedures, accreditation agency requirements, and federal, state or local law and regulations
Reviews and evaluates patient caseload for appropriateness of setting, medical necessity using InterQual, quality of care, continuum of care needs and provide complete documentation daily.
Coordinates care delivery in consultation with the healthcare team and revises plan of care to assure progress toward defined outcomes.
Identifies cases requiring physician advisor review, refers cases in a timely manner, and assists physician advisors with reviews and communications with attending physicians, government agencies, and third party payers.
Documents consistency and appropriately.
Anticipates aftercare needs & assists with the plan in collaboration with healthcare team.
Gathers avoidable and prevented delays in care and reports them weekly.
Creates a communication mechanism that is efficient for all members of the healthcare team. Provides pertinent education to other staff and physicians including CMS and guidelines.
Demonstrates an in-depth knowledge of individual regulations relating to third party payers, Federal/State governments, and the peer review organizations and has the ability to communicate the information effectively to patients/families.
Arranges and participates in third party payer hearings and appeals, and communicates the results to the medical staff in a timely manner.
Assists Medical staff in denial management.
Contributes to the success of the organization by meeting organizational competency expectations, continuously learning, and by performing other duties as needed or assigned.
Applies discharge screens appropriately to identify potential premature discharges or inappropriate utilization of hospital services and refers cases for physician advisor review.
Participates in ongoing data studies to ensure an accurate database is available for reporting; Retrieves, formats, and displays statistical data.
Facilitates interdisciplinary care conferences.
Contacts the attending physician for additional information if the patient does not meet criteria. If the patient still does not meet criteria for admission, contact the Physician Advisor or their designee for secondary review per escalation policy.
Understands and utilizes the EMR/Cerner systems to perform daily tasks.
Assists with delivery and appeal process regarding Important Message from Medicare.
Assists the CDMP process according to established policies and procedures.
Utilizes a follow-up mechanism to assess the satisfaction, functional status, and clinical outcomes of a certain population of patients with CHF.
Reviews patient assessments on an ongoing basis to determine if needs are being met upon admission, coordinates additional services, and institutes discharge planning.
Coordinates ischarge from acute care into swing bed maintaining continuity of care services.
Provides continuous education regarding the swing bed program to staff and physicians.
Identifies potential quality and/or risk issues and concerns and reports those to the appropriate areas.
Performs retrospective medical record audits to assure ongoing compliance and integrity of the program, as requested.
Assesses tests or procedures to ensure they meet medical necessity appropriateness such as, MRI’s, unrelated surgeries or awaiting biopsy results and assist in arranging those as outpatient.
Obtains approval for patients requiring pre – certification prior to admittance to Swing Bed.
Completes concurrent/ continued stay up-dates when required.
Participates in weekly care conferences to assist in identify potential internal swing bed candidates.
Contributes to the formulation and updating of unit policies, procedures, and protocols, and adheres to these and other professional and regulatory standards
Ability to explain and deliver Important Message from Medicare, IMM, Discharge Appeal rights, Hospital Issuance of Notice of Noncoverage (HINN) for Inpatients, Commercial Waivers or Advance Beneficiary Notice (ABN) for Outpatient/Observation to patients/families as necessary.
Applies and effectively uses problem solving techniques and conflict resolution skills to coordinate care for the patient.
Demonstrates skill in understanding the range of skilled level of care treatments along with the knowledge of the principles of growth and development of the patients served.
Other duties as assigned
**Will work weekends as assigned