Registered Nurse (RN) -Hospital Case Manager, Pediatrics, Part-Time

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Job Summary

The RN-Patient Progression Leader provides case management services for hospital patients, including, but not limited to, utilization management to ensure efficient, cost-effective patient progression through the continuum of care and discharge to an appropriate level of care. In collaboration with physicians, leads the multidisciplinary team including clinical staff and payors to ensure efficient delivery of quality, cost-effective care.

Accountabilities

Works collaboratively with Unit team, RN-Clinical Care Coordinator, Social Worker and Revenue Cycle to progress each patient's care towards discharge.

Discharge Planning/Care Coordination

1. Evaluates discharge needs upon admission, ensuring each patient has a complete discharge plan.

2. Identifies and escalates barriers to discharge as identified.

3. Identifies potential discharges and delegates updates of Estimated Day of Discharge time in Epic.

4. Documents avoidable delays in Epic, daily.

5. Identifies and escalates barriers to discharge as identified.

6. Verifies regular follow up appointments are scheduled.

7. Medication Vouchers.

8. Verify transportation prior to day of discharge.

Utilization Management

1. Completes UM (Complete concurrent/continuous stay reviews) to assure that all payor and status requirements are aligned according to patient's clinical progression and governmental regulation per CMS guidelines.

2. Reviews Physician admission order and validates status and level of care matches order.

3. Serves as a consultant and educator with medical staff regarding status, placement, payor requirements, and utilization of resources.

4. Identifies opportunities to transition testing to the outpatient setting and escalates as appropriate.

Professional Development

1. Maintains expert level knowledge of body systems and expected clinical outcomes for patient disease process.

2. Maintains current knowledge of changes in state and federal regulatory requirements related to the provision of case management services in a tertiary acute care setting.

3. Maintains case management knowledge to provide services in accordance with standards of practice as established by department and leadership.

• Responsible for discharge activities for non-complex discharges, collaborates with Social Worker.
• Reviews LOS values and working DRG daily; updates in EMR as needed; Ensures patient is meeting TLOS.

Proactively monitors patients in observation or outpatient status by completing a medical necessity review in the EMR and progresses accordingly; escalates outliers to leadership as appropriate.

Financial Performance

1. Promotes effective and efficient utilization of clinical resources, ensuring quality, cost effective care.

2. Provides timely clinical reviews to third party payors. Responds to requests for additional information within 24 hrs or next business day.

3. Enters payor authorization numbers and approved days in the electronic medical record.

4. Documents denial information in EMR and coordinates peer-to-peer appeals when available.

5. Serves as a resource for patients and families with regard to their rights and responsibilities, when payment of care is denied or when care is no longer medically necessary. Includes, but not limited to, delivery of the Medicare Important Message Letter outlining the patient's rights at discharge and Medicare Outpatient Observation Notice for patients whose level of care is changed to observation.

6. Issues Medicare adverse determination letters and/or Hospital Issued Notice of Non-Coverage (HINN) when deemed appropriate.

• Identify/assess patient for readmission risk, communicates to care team, and updates Epic.
• Active participant in SNAP interdisciplinary huddles.

Minimum Qualifications

Education - Bachelor's Degree - Nursing

Experience - 3 years - Three (3) years acute care medical/surgical or critical care nursing experience. One (1) year acute case management experience preferred.

Required Licensure

South Carolina RN Licensure

Other Required Skills/Experience

• InterQual or MCG knowledge and experience - preferred.
• Utilization Management experience - preferred.

Work Shift

Weekend Shift (United States of America)

Location: Greenville Memorial Hospital

• Facility
• Greenville Memorial Hospital

Department: GMH Hospital Care Mgmt

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