The After-Hours Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified patients during an acute care episode after normal business hours. Responsible for assessing and developing a plan of care in collaboration with the admitting, attending and consultant physicians, and other healthcare practitioners after normal business hours. The After-Hours Case Manager is also responsible for developing a safe discharge plan and implementing the discharge plan for patients with the necessary resources to ensure that care is provided without interruption along the continuum of care, whether in a skilled nursing facility, assisted living facility, in the home setting, etc. after normal business hours. The After-Hours Case Manager will plan, coordinate, and collaborate with Discharge Planner to ensure the patient is receiving the best coordination of care. The After-Hours Case Manager will document based on regulatory and contractual guidelines established by Federal, State, Local and Health plan guidelines, along with policies and procedures established by the MedPOINT Management.
Duties and Responsibilities
- Screen incoming calls for admission against Milliman Care Guidelines (MCG) to determine if member requires Observation admissions vs Inpatient admission to the acute care setting.
- Act as a liaison for any member/ provider calls.
- Perform clinical review upon admission.
- Coordinate interfacility transfer of patients to tertiary facilities for higher level of care.
- Coordinate repatriation of patients from out of network facilities to their contracted/ capitated facility.
- Ensure contracted Hospitalists are utilized for admissions, transfers and repatriations.
- Documents the specific reason/s why patient is not repatriated back into network or capped facility. See Non Repatriation Codes list.
- Identify and resolve barriers or potential barriers to safe transition and outpatient management.
- Coordinate and assure all services for care transitions; including transfer to lower level of care, transfer to outpatient management, etc.
- Coordinate and facilitate Peer to Peer discussions when deemed necessary or requested.
- Endorse cases to next shift to ensure that transfers are facilitated, and the patients’ needs are met.
- Initiate and hand off case to Skilled Nursing Case Managers or Outpatient Management Programs (i.e. Hospice, etc.) as appropriate.
- Timely respond to member needs – act in the moment.
- Coordinate care for patients in the Emergency Room or Urgent Care to avoid an unnecessary acute inpatient admission.
- Timely document based on regulatory and contractual guidelines established by Federal, State, Local and Health plan guidelines, along with policies and procedures established by the MedPOINT Management and associated Participating Provider Group (PPG).
- Communicate with health plans directly on complex cases (i.e. those for higher level of care or those requiring assistance for facilities that are not contracted).
- Create letters for patients based on regulatory and contractual guidelines established by Federal, State, Local and Health plan guidelines, along with policies and procedures established by the MedPOINT Management and associated PPG’s.
- Use, protect, and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
- Consistently exhibits behavior and communication skills that demonstrate commitment to superior customer service, including quality care and concern with every internal and external member.
- Seek assistance and escalate issues when needed from the After Hours Lead and Medical Director on call for clinical oversight and decision making.
- Perform other duties as assigned.
- Schedule will vary but must be available for a minimum of 4 shifts per week, weekends, holidays, and other unscheduled closures of MedPOINT Management.
Minimum Job Requirements
- Current RN or LVN licensure; Preferred: BSN level of education.
- Registered Nurse or Licensed Vocational Nurse with clinically focused work history.
- Prefer three-five years clinical experience within an acute health care setting with recent work history in acute care case management role or related health care experience.
- Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review/quality assurance, use of Milliman or other clinical decision support criteria, discharge planning, and reimbursement structures (i.e. Government and non-governmental payers).
- Ability to read, analyze and comprehend complex clinical data and its application to level of care criteria and discharge options; strong, broad-based clinical knowledge and understanding of pathology/physiology of disease processes; excellent critical thinking skills; assertive personality traits to facilitate ongoing physician communication; organize, prioritize and manage time efficiently.
Skills and Abilities
- Computer literacy and familiarity with the operation of basic office equipment.
- Proficient in Excel and Word.
- Knowledge of EZ-Cap.
- Must be able to communicate effectively with a wide range of hospital personnel, physicians, patients/family members within various socioeconomic groups and representatives of varied outside agencies.