Orthopedics and Sports Medicine Case Manager

Report to : Director of Orthopedics 

FLSA Classification: Full Time, Non Exempt, Hourly $36.50- $52.20

Essential Functions:

• Communicates, collaborates, and maintains effective working relationships with the healthcare team regarding the appropriate utilization of acute inpatient hospital services and development and actualization of the discharge on a daily basis.
• Maintains effective working relationships with insurance representatives as well as agencies and facilities that provide post-discharge services.
• Serves as a resource to:
• Patients and families on the concept and process of managed care, as well as the concept, process, and goals of case management.
• Hospital staff on the concept, process, and goals of case management at PMC, the importance of medical record documentation in meeting standards of professional practice, and to ensure optimum communication and reimbursement.
• Members of the interdisciplinary team on managed care requirements and their implications for patient care.
• Prevention of illness and health maintenance.
• Participates in the evaluation and effectiveness of community resources utilized for providing home health and other discharge services.
• Meets continuing education requirements to maintain licensure in Colorado.
• Attends continuing education programs pertinent to specialty care.
• Pursues continuing education opportunities in case management concepts and practice.
• Maintains membership in pertinent professional organization(s).
• Maintains Current Knowledge of:
• Managed care requirements for inpatient utilization of services.
• Community resources including home health agencies, chronic/rehabilitation hospitals, skilled nursing facilities, home infusion and durable medical equipment vendors and special service providers
• Case management process and patient care costs relative to reimbursement. 
• Insurance requirements and practices
• Patients and families on the concept and process of managed care, as well as the concept, process, and goals of case management.
• Hospital staff on the concept, process, and goals of case management at PMC, the importance of medical record documentation in meeting standards of professional practice, and to ensure optimum communication and reimbursement.
• Members of the interdisciplinary team on managed care requirements and their implications for patient care.
• Prevention of illness and health maintenance.
• Managed care requirements for inpatient utilization of services.
• Community resources including home health agencies, chronic/rehabilitation hospitals, skilled nursing facilities, home infusion and durable medical equipment vendors and special service providers
• Case management process and patient care costs relative to reimbursement. 
• Insurance requirements and practices

Patient Care Management:

• Screens all patients referred to the Case Manager for appropriate management and plan development.
• Collaborates and participates with the unit and/or specialty-based clinical nurse specialist, the primary nurse, and the physician in the ongoing clinical assessment of the patient's status and care management.
• Serves as the leader of the Med/Surg/Ortho Case Management Team and directs/utilizes Resources to ensure quality outcomes for the patient by performing the following:
• Confirms demographic information with patient/family.
• Determines the necessity of intervention and the appropriate level of care.
• Develops plan of care in conjunction with the healthcare team.
• Provides emotional support to the patient/family during the patient's illness in conjunction with the medical and nursing staff.
• Ensures that the patient and family receive consistent information regarding the anticipated length of stay, treatment plan, and discharge care plan.
• Communicates and collaborates:
• With clinic, surgery, providers, midlevels, CRNAs, and other staff to ensure patient needs are met.
• To ensure that case management needs of assigned patients are met without duplication of efforts.
• To ensure adequate documentation in the patient's medical records on a daily basis.
• To ensure appropriate individual(s) or group(s) address systems or practice patterns identified through variance data analysis as necessary.
• Performs other duties as required.
• With clinic, surgery, providers, midlevels, CRNAs, and other staff to ensure patient needs are met.
• To ensure that case management needs of assigned patients are met without duplication of efforts.
• To ensure adequate documentation in the patient's medical records on a daily basis.
• To ensure appropriate individual(s) or group(s) address systems or practice patterns identified through variance data analysis as necessary.

Discharge Planning:

In collaboration with the Social Worker, the Case Manager is responsible for directing and utilizing resources for discharge planning

• Pre-operatively assesses the expected level of care required for post-discharge services and the linkage to existing community/health services.
• Serves as a resource to the interdisciplinary team for discharge planning options and assessing the financial impact.
• Interacts with home care agencies and facilities to ensure safe and timely discharge as needed.
• Ensures follow-up contact with patient/family and community agency or facility to evaluate the effectiveness of the discharge plan.
• Ensures coordination of the communication process with patient/family concerning the discharge plan, including coordination of family meetings.
• Identifies and addresses system issues and makes recommendations.
• Removes barriers and makes recommendations.

Quality Improvement Activities/Variance Tracking, Directs data collection services:

• Participates in quality improvement activities designed to evaluate the appropriateness and effectiveness of the service delivery system in which case management operates.
• Participates in the development or revision of hospital policies pertaining to admission, discharge, and patient care processes.
• Collects and analyzes variance data to identify opportunities for improvement in hospital-wide systems for the delivery of patient care, re: LOS, cost, practice patterns, charges, and efficiencies or lack thereof, current trends, and analyzes reports.
• Provides data for the Utilization Review Committee.

Fiscal:

Under the direction of the Service Line Administrator and in collaboration with the Case Management Coordinator.:

• Analyzes data and makes recommendations to change medical practice to enhance efficiency.
• Acts as liaison between fiscal and clinical areas and provides data to maximize reimbursement.

Education And Experience:

• Current, unencumbered Colorado Nursing license required.
• Current BLS within three (3) months of hire required.
• CCM or ACM certification preferred.
• Graduate of an accredited school of nursing required, BSN preferred.
• Five to seven years in case management in an acute hospital setting is strongly preferred. 
• Experience in quality improvement and/or case management, discharge planning, or utilization management is required or strongly preferred.
• Demonstrated leadership and management ability
• Demonstrated ability in and knowledge of complexities in managing patients across the continuum of care
• Demonstrated knowledge and ability in the intricacies of managed care and reimbursement
• Advanced analytical, writing, and speaking ability to meet all responsibilities
• Grasp of learning theories and teaching techniques
• 3 Years previous direct patient care, Case Management/Utilization review preferred