The individual in this position is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patientï¿½s resources and right to self-determination. The individual in this position has overall responsibility to ensure that care is provided at the appropriate level of care based on medical necessity and assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable re-admissions. This position integrates national standards for case management scope of services including:
Provides assistance to the Director of Case Management in the management of the department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments
Utilization Management supporting medical necessity and denial prevention
Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
Care Coordination by demonstrating efficient throughput while assuring care is sequenced and at the appropriate level of care
Accountable for compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
Provides education to physicians, patients, families and caregivers
Facilitates educational programs for Case Management Department on community resources use in discharge planning that encourages professional growth
Provides reports to DCM and hospital leadership as requested
The individualï¿½s responsibilities include the following activities: a) assist the Director in the daily operations of the department b) accurate medical necessity screening and submission for Physician Advisor review, c) transition planning assessment and reassessment, d) implementation or oversight of implementation of the transition plan, e) leading and facilitating multi-disciplinary patient care conferences, f) managing concurrent disputes, g) making appropriate referrals to other departments, h) identification and reporting over and under-utilization, i) communicating with patients and families about the plan of care, j) collaborating with physicians, office staff and ancillary departments, k) leading and facilitating Complex Case Review, l) assuring patient education is completed to support post-acute needs , m) timely complete and concise documentation in Tenet Case Management documentation system, n ) maintenance of accurate patient demographic and insurance information, o) identification and documentation of potentially avoidable days, p) and other duties as assigned.
Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast paced environment, critical thinking and problem solving skills and computer literacy.
While performing the duties of this job, the employee is regularly required to sit, talk, and hear. The employee is frequently required to use fine motor skill (typing/data entry), and reach with hands and arms. The employee is frequently required to stand; walk; and occasionally stoop, kneel, or crawl. The employee must regularly lift and /or move up to 20 pounds and occasionally lift and/or move up to 50 pounds.
Individual works in a fast paced clinical and office environment.
Must complete Tenetï¿½s InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Attendance at hospital and department orientation is required. Department orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQualï¿½, Transition Management, Utilization Management, and other topics specific to case management.
PRIMARY INFORMATION, TOOLS AND SYSTEMS USED
Patient data ï¿½ hospital admission, discharge, transfer system
Healthcare staff documentation related to patient care
Regulatory and payor requirements
Allscripts ï¿½, MIDAS & other Care Management Documentation Systems
McKesson Care Enhance Review Manager (CERMe) InterQual system
Clinical data interface and secure faxing
Patient Medical Record including Cerner, Mc Kesson, Meditech, EPIC and HPF
Hospital specific Clinical Software
POSITION SPECIFIC RESPONSIBILITIES:
Oversees an adequate number and skill mix of staff over seven days a week to serve the patient population and meet the goals of the department
Supports and manages staffing requests utilizing the Tenet Case Management staffing recommendations within budgetary guidelines
Plans and conducts regular departmental meetings with the Director to provide staff updates and ongoing education
Assists the Director with the implementation of the InterQual Inter-rater Reliability (IRR) Policy to determine initial and yearly competency for all employees performing InterQual reviews
Ensures new Case Management staff complete department orientation including review of Tenet Case Management and Compliance policies and Documentation training
Assists the Director of Case Management in the management of the department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments
Monitors case management processes and staff productivity to ensure medical necessity reviews are completed timely and accurately, payer communications are sent and authorizations or denials documented and followed up, and that transition planning assessments are completed timely.(30% daily, essential)
Monitors the review process to ensure medical necessity patients to be in the appropriate status and level of care per Tenet policy
Oversees submission of cases to Physician Advisor to ensure timely referral, follow up and documentation
Monitors the timely communication clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services
Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
Participates in Revenue Cycle meeting, researching disputes, uncovering patterns/trends and educating hospital and medical staff on actionable items
Implements and monitors physician ï¿½peer to peerï¿½ review process with payers to resolve denials or downgrades concurrently
Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
Utilizes Crimson data to provide timely and meaningful information to the Utilization Management Committee and physician staff for performance improvement.
Assists the Director in monitoring to ensure that CMS Follow-up Important Message (IM) and HINN letters are delivered and documented per federal regulations and Tenet policy.
Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
Identifies and documents Avoidable Days using the data to address opportunities for improvement
Prevents denials and disputes by communicating with payers and documenting relevant information
Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements.(20% daily, essential)
Implements and monitors process to ensure that a transition plan assessment is completed within 24 hours of patient admission to identify and document the anticipated transition plan for patients
Ensures case management staff use electronic referral request process for patient placements
Monitors to ensure that patient preference & choice is documented per CMS regulations and Tenet policy
Monitors to ensure case management staff document in the Tenet Case Management documentation system to communicating information through clear, complete and concise documentation
Ensures compliance that Case Management Staff are completing comprehensive assessments within 24 hours of patient admission to identify and document the anticipated transition plan for patients
Integrates key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan
Identifies patients at risk for readmission and applies appropriate intervention including risk assessment and referral to Social Work and/or Complex Case Review
May delegate the implementation of the transition plan to LVN/LPN or Assistant staff and follows up to ensure the transition plan is completed timely and accurately
Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers
Ensures all Final Discharge Disposition Form are completed for Medicare beneficiaries per Tenet policy
Accountable to identify and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes documentation in the Tenet Case Management documentation system to communicating information through clear, complete and concise documentation (20% daily, essential)
Assists the Director in working with Nursing and hospital leadership to ensure Patient Care Conferences and Complex Case Review processes are in place to promote timely and appropriate throughput
May participates in daily bed management meeting to support timely and effective patient placement and transfer within the hospital
Monitors to ensures that patients have a plan of care that is clinically appropriate, consistent with patient preference & choice and available resources
Monitors to ensures consults, testing and procedures are sequenced to support clinical needs with timely and efficient care delivery
Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical outcomes
Ensures the plan of care is clinically appropriate, consistent with patient preference & choice and available resources(10% daily, essential)
Ensures and provides education to patients, physicians and the healthcare team relevant to the
Effective progression of care,
Appropriate level of care, and
Safe and timely patient transition
Provides patient and healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options
Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge
Provides in-service education to Case Management Department on community resources
As team leader of discharge planning unit provides guidance and monitoring of activities of discharge planning unit(10% daily, essential)
Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies
Operates within the RN scope of practice as defined by state licensing regulations
Remains current with Tenet Case Management practices (10% daily, essential)
PERFORMANCE METRICS AND EVALUATION
The metrics below provide an indication of the effectiveness of the individual in this role and may be used for evaluative purposes. The list below is not meant to be exhaustive; other relevant metrics may exist.
InterQual reviews completed accurately and timely
Observation length of stay
Clinical disputes - incidence and dollars
Clinical Reviews & Authorizations
Position documentation and productivity
Oversees staff assigned to Case Management Department, including, but not limited to, RN and LVN/LPN Case Managers, Social Workers, Case Manager Assistants, Authorization coordinators, and Discharge Planners.
REQUIRED: An active Registered Nurse license with at least two years acute hospital patient care, hospital case management, healthcare, or leadership experience.
PREFERRED: B.S.N. preferred, ***unless higher degree required for Magnet Hospital Status. Accredited Case Manager (ACM) preferred. Acute hospital case management experience preferred.
Primary Location: Phoenix, Arizona
Facility: Abrazo Region
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 1905022091
About Abrazo Region
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.