Case Manager-RN / Full Time-40 hours

Job Summary

Under the general supervision of the Director, nurses in the Case Manager role provide

clinically-based case management services to support the delivery of safe and efficient patient care.

Has overall accountability for utilization review and transition planning for patients within the

assigned caseload. Partners with Social Work , along with other health care team members, to

ensure appropriate utilization of resources and to improve Patient outcomes. Utilizes nationally

established criteria to confirm medical necessity for hospital admission and continued stay. With the

patient, family and health care team, creates a discharge plan appropriate to the patient’s needs,

resources, and desires.

Essential Job Functions and Responsibilities :

Determines medical necessity, appropriateness of admission, continued stay and level of care using a

combination of clinical assessment and nationally established criteria. Intervenes when determinations

are not in alignment with clinical information, clinical criteria or third party information to resolve the

situation. Documents information in the current electronic medical record (Meditech)

Validates admission and continuing stay criteria with third party payers (including onsite and telephonic

Case Managers) as well as Primary Care and Attending Physicians. Recommends alternative care sites

when and where appropriate. Helps establish insurance authorization and transport in such situations.

Collaborates with third party payers to maximize reimbursement. Anticipates denial of payment and

proactively addresses issues contributing to a potential denial. Intervenes to prevent a denial whenever

possible.

Assesses the patient and family for continuing care needs to develop, implement and evaluate an

effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual

length of stay to timely plan for discharge.

Collaborates and communicates with patients / families related to the current inpatient stay. Seeks family

input and actively encourages patient preference and choice in establishing a discharge plan.

Uses clinical knowledge to assess Patient response to treatment. Monitors patient progression towards

goals and anticipated outcomes. Queries clinicians when goal progression has stalled or veered away

from expectations. Communicates with Physician advisor to seek advice and clarity. Addresses

actual / potential barriers to discharge.

Completes the interventions necessary for discharges to home with self-care, home with services and

short term skilled nursing facility placement. Assembles necessary referrals, discharge summaries and

pertinent information for placement prior to the day of discharge.

Actively contributes to, participates in, and follows through on interventions identified in care

coordination and complex patient rounds.

Identifies high risk patients and creates a collaborative plan to address their unique needs.

Qualifications

Educational / Minimum Requirements

3+ years of clinical experience, predominately in medical / surgical nursing is ideal

Case Management, discharge planning and utilization review experience preferred.

Licensed as a Registered Nurse in the State of Connecticut

BSN strongly preferred or working toward that goal.

Bristol Hospital Mandated Educational Requirements :

General orientation at time of hire. Fire / Safety / Infection control annually. Other programs as mandated by Hospital.

Physical Requirements :

Considerable walking, standing, sitting, stooping and bending. Considerable paperwork and video display terminal work requiring extensive eye usage.

Work Environment :

Normal nursing unit environment, including patient furnishings and equipment.

Special Requirements :

Strong interpersonal, communication, and negotiation skills.

Ability to form positive, collaborative relationships with hospital staff, patients and families.

Ability to effectively negotiate with internal and external providers of patient care services.

Analytical abilities to assist in obtaining solutions to problems.

Able to work independently and prioritize work.

Able to manage multiple priorities.

Basic knowledge of computers and clinical applications.

Ability to problem solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge.

Communicate in a clear, concise, and logical manner in oral and written presentations.

Must be willing to be floated or reassigned to another department, unit, office, or location as needed.