About the job

Under general supervision, manages and coordinates process of care for inpatients to facilitate quality cost-effective patient outcomes. Works collaboratively with interdisciplinary staff internal and external to the organization. Coordinates with payer and physicians to ensure the maximum reimbursement for the hospital through the utilization review process. Responsible for discharge planning and coordination of care with interdisciplinary team. Collaborates with service line team members to distribute patient case load.

Education

Bachelor of Science in Nursing (BSN) OR Associate of Science in Nursing and currently enrolled in a BSN program with an expected graduation date within three (3) years

Experience

Two (2) years of Case Management which includes Utilization Review, Discharge Planning and working with Re-Admission Initiatives.

Diversified, progressive experience in acute care and/or other settings within the continuum preferred

Skills

• Knowledge of Interqual and/or Milliman criteria
• Knowledge of care management theories, principles, and standards
• Skill in using computer software programs
• Advanced skill in oral and written communication
• Advanced skill in critical thinking
• Ability to resolve complex problems
• Ability to remain calm under pressure and intense time constraints
• Ability to assess discharge needs for patients

Principal Duties And Responsibilities

• Assesses patients within a defined caseload to identify clinical status, needs, issues, financial resources, and care goals; demonstrates knowledge of reimbursement mechanisms. Considers patient’s financial resources for meeting healthcare needs (insurance reimbursement, managed care plans, entitlement programs, and personal resources).
• Continually assesses patient care management needs through frequent rounds and communication with physicians and other appropriate members of the health care team. Serves as liaison for the patient, physician, and health care team to implement the processing of the patient centered plan throughout the continuum.
• Reviews the appropriateness of admission and continued stay criteria for a defined group of patients and either develops a concurrent stay and/or discharge plan of care in accordance with payer and clinical guidelines.
• Identifies, plans, modifies, and coordinates patient discharge needs, making appropriate referrals, and utilizing available community resources as needed for implementation. Formulates a plan that addresses the continuing needs of the patient following discharge from the acute care setting.
• Maintains a working knowledge of the requirements and clinical criteria guidelines of payers. Coordinates services with managed care companies and other third party payers. Discusses on-site reviewer issues with payer, either via the telephone or in person. Assures timely utilization compliance with all payers who require authorizations.
• Provides necessary services for effective post discharge placement in another facility, by obtaining necessary pre-authorization, transportation, and contacting (if necessary) the proposed facility regarding clinical information and services required.
• Identifies the need for, arranges, and conducts health care team meetings when necessary to facilitate the coordination of care and discharge planning for complex patients and high utilization of resources.
• Participates in education of physician, ancillary, and nursing staff regarding care management, financial and clinical outcomes, as well as documentation requirements/standards.
• Identifies service specific procedures and system obstacles that affect patient outcomes. Consults with health team members to address problems and makes recommendations to resolve them. Collaborates with social work on complex discharge planning needs.
• Keeps management informed and up to date on clinically complex, emotionally intense, politically sensitive, and financially weighty cases, offering possible solutions through discussion and feedback.

All Roles Must Demonstrate GBMC Values

Respect

I will treat everyone with courtesy. I will foster a healing environment.

• Treats others with fairness, kindness, and respect for personal dignity and privacy
• Listens and responds appropriately to others’ needs, feelings, and capabilities

Excellence

I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.

• Meets and/or exceeds customer expectations
• Actively pursues learning and self-development
• Pays attention to detail; follows through

Accountability

I will be professional in the way I act, look and speak. I will take ownership to solve problems.

• Sets a positive, professional example for others
• Takes ownership of problems and does what is needed to solve them
• Appropriately plans and utilizes required resources for various job duties
• Reports to work regularly and on time

Teamwork

I will be engaged and collaborative. I will keep people informed.

• Works cooperatively and collaboratively with others for the success of the team
• Addresses and resolves conflict in a positive way
• Seeks out the ideas of others to reach the best solutions
• Acknowledges and celebrates the contribution of others

Ethical Behavior

I will always act with honesty and integrity. I will protect the patient.

• Demonstrates honesty, integrity and good judgment
• Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

Results

I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.

• Embraces change and improvement in the work environment
• Continuously seeks to improve the quality of products/services
• Displays flexibility in dealing with new situations or obstacles
• Achieves results on time by focusing on priorities and manages time efficiently

COVID-19 Vaccination

All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.