Director of Case Management/Centralized Scheduler

CASE MANAGEMENT DIRECTOR AND CENTRAL SCHEDULER JOB DESCRIPTIONS CASE MANAGMENT DIRECTOR POSITION SUMMARY

Coordinates, plans, manages and evaluates all operational activities of case management across all care settings. Directs and supervises all case management staff. Lead Utilization Review (UR) Coordinator, Discharge Planner, and Swing Bed Coordinator. Responsible for ensuring case management clients receive appropriate services across the continuum of care, ensuring adherence to national industry standards and corporate standards of practice. Performs duties in a patient-centered manner and involves patients/families in plan of care. Responsible for UR Performance Improvement (P.I.) Analysis and preparation of reports to be presented to P.I. Committee. Performs inpatient, outpatient, concurrent admission, and procedure reviews using the standardized level of care criteria selected by the facility to determine necessity, appropriateness, and efficiency of admissions, procedures and extended duration reviews. Obtains authorizations for outpatient and inpatient procedures, inpatient admissions, and observation beds. Obtains retro-authorizations when requested by billing/financial services. Performs appeals for denials and arranges physician peer to peer reviews when appropriate. Promotes good public relations through contacts with physicians, fellow employees and patients in which services are being rendered. Maintains appropriate documentation for all Utilization Review (UR) transactions. Responsible for observation, inpatient, and swing bed level of care criteria determination and payor authorizations. Responsible for patient care transitions by arranging for prescribed medical alternative treatment or other plans of care, as needed, when the patient is discharged from the hospital to promote continuity of care. Assist patient and their families in decision making regarding providing the best possible level of care with least restrictions of the patient, whether the service provided is to be continued in-home care or out-of-home care setting. This should provide provision for, or referrals to, services that may be required to improve or maintain the patient's health status. Participates in patient care transitions process, including discharge/transfer instruction education of the patient both prior to and after discharge from hospital. Consults with a qualified Social Worker or Certified Case Manager as needed. Responsible for swing bed necessity determinations, authorizations, admissions, and documentation. Assists patient with activities as another modality in the total care plan that specifically address the individual patient problems/needs and help the team meet the care goals for that person. Assists Centralized Scheduler with scheduling duties, as needed, in facilitating the scheduling process for hospital and outpatient patients via scheduling procedures Monday through Friday Days. Obtain essential information for registration, scheduling, and insurance referral. Provide customer service to patients, care providers, and others, through effective, timely communication such as telephone triage, email, and written correspondence. Communicates with a variety of clinical disciplines including physicians, advanced practitioners and nursing staff to clarify medical necessity and to obtain needed information for Payor authorizations. Must be able to work well in fast-paced, continual changing environment, with minimal supervision and ability to problem solve through respectful communication. Works throughout hospital with a work area provided in Case Management Office.

PRIMARY RESPONSIBILITIES & AUTHORITIES

Champions the Case Management process by establishing and maximizing the Case Management Program across our organization and ensures its impact across the healthcare continuum for all indicated clients. Serves as Case Management Department Director, directly supervising other Case Managers and Centralized Schedulers. Lead Utilization Review (UR) Coordinator oversees appropriate authorizations for outpatient and inpatient procedures, inpatient admissions, and observation beds are obtained and documented. Lead Discharge Planner Coordinator oversees coordination of assessments and screening, third party payor authorization, and discharge activities providing linkages to health and wellness resources across the health care continuum. Lead Swing Bed Coordinator oversees overall implementation of Swing Bed Program under established guides and provide staff education regarding swing bed issues. Coordinate Case Management Interdisciplinary Team Meetings, sharing data collection/analysis, participating in communication and interdepartmental problem solving as to benefit an individual patient, or hospital as a whole. Actively participates and facilitates tracking of cost, resource management and quality improvement parameters. Performs data collection, analysis, and report generation as assigned to facilitate performance improvement and quality initiatives as set by the Management Team. Obtain admission office information on all patients (patient census record), receive admission requests, pre-op schedules, and orders from the admissions office, surgery, and/or physician clinical staff of services to be performed in an observation, inpatient, or swing bed setting. Performs admission, concurrent, and retro reviews using the current Level of Care criteria standards selected by the facility and according to criteria developed and approved by LH Critical Access Hospital Guidelines. Serves as a Utilization Review and Discharge Planning Resource for members of the medical and hospital staff by the triage of patients to appropriate level of care through discussions with attending physician and nursing staff and by initiating a plan for post-hospitalization of care when indicated. Works with the patient/family/caregivers and physician to screen patients and help decide appropriate discharge plans. Then, plans for the need for continuing care assistance, post-hospitalization, and makes arrangements/referrals for placement at appropriate agency in skilled, intermediate, personal care, assisted living facilities, and/or care in the home (Home Health, Hospices, etc.), as applicable. Enables patient and their families to understand, accept, and follow medical recommendations through individual or group conferences. Receive referral from physicians, nursing staff, or any other department of the hospital who observes patient needs and discusses with healthcare team member's aspects of patient's care to assist with planning the best level of care with least restrictions after discharge. Evaluates the patient insurance coverage and proposed procedure for the appropriate care setting, contacts insurance for authorization of procedure, outpatient or inpatient hospitalizations, and/or swing bed level of care to include but, not limited to, ambulance transfers, etc. and alternative options across the care continuum. Makes indicated client referrals. Interfaces with external reviewing/paying agencies regarding review of specific cases for medical necessity and appropriateness. Interview patients and/or families in securing background information and evaluating factors significant in providing continued patient care. Performs social assessments for care transitions. Interviews patient/family/care givers/primary care provider of the patient to obtain information about living conditions, financial, social, and emotional environments of the patient. Assess the patient's psychosocial and spiritual needs and interests. Contacts community resources, such as senior citizens center and other pertinent sources, such as durable medical equipment companies, in order to mobilize environmental services on the patient's behalf. Keep patient and/or family members informed of updates regarding transition/discharge plans and provide patient teaching to enable understanding of medical recommendations with an appropriate reading/comprehension level. Collaborate and communicate regularly with hospital personnel on progress of continued plan of care and incorporate activity goals and interventions for the identified physical and psychosocial problems. Develop and implement individual and/or small group activities to achieve identified goals congruent with the physician's plan of care, coordinate activities with other patient services, and document the patient's response to the plan (i.e. achieving the treatment goals). Consults and refers cases for physicians review by providing accurate, complete, and objective information regarding the patient's clinical situation and plan of care. Follow up call to high-risk and designated patients post hospitalization according to criteria/guidelines implemented at LH to provide problem solving and intervention to prevent potential preventable re-hospitalizations. Maintains responsibility for post hospitalization care plan (discharge instructions) to be provided to after-hospital medical services, including primary care physicians and specialists. Make adequate, concise entries in the patient's Electronic Medical Record in an effort to promote regular communications with physicians, nurses, and other personnel involved in the patient's care. Schedule appointments accurately and according to the availability of the various departments, as needed. Completes pre-registrations including insurance verification, eligibility, and requests referral and pre-certification number from PCP at the time of scheduling the appointment, as needed. Coordinates multiple appointments from calls and orders work queues, as needed. Reschedules and cancels appointments and communicates as needed with patients/families and departments/clinics, as needed. Demonstrates positive customer service when greeting patients, care providers, and others. Assure the patient has all the information they need so they will arrive on time and prepared for their procedures and that the hospital has all of the information required to bill properly for its services. Provides patient/family accurate service instructions and directions/maps prior to appointment as directed by service department so that all departments may view and print the schedule for the daily appointments, and maintain open communication with hospital departments regarding schedule changes, as needed. Secures demographics, guardian and emergency contacts, guarantor, and coverage information, updating registration when patient's information changes. Develops and maintains good working relationships with other hospital personnel, community health, welfare and social agencies. Must have full knowledge and ability to access and assign ICD-10-CM and CPT codes for proper diagnosis and procedures. Maintains confidentiality of all information obtained during performance of job duties, as in accordance with HIPPA rules and regulations. Assists with maintaining work logs of reviews of admission, procedures, concurrent, and/or retrospective reviews. Maintains a clean and well-organized work area.

OTHER DUTIES AND RESPONSIBILITIES

Participating in clinical pathway development processes, evaluation of service efficiency and excellence, and client education. Supports physicians in medical case management, Chief of Medical Staff, and Administration in key performance improvement initiatives as assigned, outcomes/performance reviews as indicated. Participates in departmental director meetings and meets organizational educational requirements. Other duties and responsibilities as directed by the Chief Executive Officer and/or Chief Financial Officer. Lead Utilization Review Coordinator responsible for Utilization Review P.I. analysis and participates in Quality and Performance Improvement reviews to include data collection for analysis. Assists Centralized Scheduler with scheduling duties, as needed. Meet requirements for CEU's to keep certification(s) current. Assists with discharge/transfer process when needed via obtaining necessary documentation and provision of documents (history, progress notes, MAR, labs, etc.) and patient information to complete a seamless patient level of care transition according to policies.

MINIMUM QUALIFICATIONS

(EDUCATION, EXPERIENCE, SKILLS, ABILITIES): Must be a graduate from an accredited school of nursing with a minimum of Associates Degree of Nursing required, Bachelor's Degree preferred. Five years acute care experience required. Case Management experience preferred. Utilization and Quality Management experience preferred. Proven skills in assessing, planning, and managing patient care required. Basic knowledge of national utilization standards and case management standards of practice needed. Knowledge base of various computer software and use of computers, including keyboarding/typing skills required (i.e. Microsoft Office, Excel, and Word). Basic knowledge of statistics required. Excellent communication skills, verbal and written are mandatory. Excellent customer service, problems-solving skills, prioritization, and organization are essential. Must display an ability to build positive relationships with medical staff. Ability to be thorough, pay close attention to detail, and follow detailed instructions with good time management skills.

OTHER SPECIAL REQUIREMENTS

(LICENSES, CERTIFICATIONS, REGISTRATIONS, ETC.) Must hold and maintain current, valid, and unrestricted Registered Nurse License through the Kentucky Board of Nursing. Must possess or be working toward certification in case management. Membership with a professional case management organization encouraged.

PHYSICAL DEMANDS

May remain seated for extended periods of time. Use of telephone for long periods of time (earpiece available for use). Some walking required for reviews and errands throughout facility; bending, stretching, and/or lifting may be required. Ability to use hands for typing, taking notes, and messages is required. Interactions with patients and their caregivers/family members will occur.

WORK ENVIRONMENT

Well lighted, ventilated, and climate -controlled area within the hospital. May come in contact with body fluids, blood, and various infectious diseases while interacting with patients. Shared office space with other case management personnel. May organize outdoor activities, weather permitting.

CENTRALIZED SCHEDULER JOB DESCRIPTION POSITION SUMMARY

Facilitate the scheduling process for hospital and outpatient patients via scheduling procedures Monday through Friday Days. Obtain essential information for registration, scheduling, and insurance referral. Provide customer service to patients, care providers and others through effective, timely communication such as telephone triage, email and written correspondence. Perform other scheduling duties as requested. Assists Lead Utilization Review Coordinator (director), and other members of Case Management, in evaluating the patient's insurance coverage and proposed procedure for the appropriate care setting, contacts insurance for authorization of procedure, outpatient or inpatient hospitalizations, and/or swing bed level of care to include, but not limited to, ambulance transfers, etc.

PRIMARY RESPONSIBILITIES & AUTHORITIES

Schedule appointments accurately and according to the availability of the various departments. Completes pre-registrations including insurance verification, eligibility, and requests referral and pre-certification number from PCP at the time of scheduling the appointment. Coordinates multiple appointments from calls and orders work queues. Receives requests to schedule procedures from physician offices and patients and schedules the procedure according to the availability of the various departments Provides accurate information so that all departments may view and print the schedule for the appointments daily, and maintains open communication with hospital departments regarding schedule changes Reschedules and cancels appointments and communicates as needed with patients/families and departments/clinics. Demonstrates positive customer service when greeting patients, care providers, and others. Assure the patient has all the information they need so they will arrive on time and prepared for their procedures and that the hospital has all of the information required to bill properly for its services. Provides patient/family accurate service instructions and directions/maps prior to appointment as directed by service department so that all departments may view and print the schedule for the daily appointments, and maintain open communication with hospital departments regarding schedule changes. Secures demographics, guardian and emergency contacts, guarantor, and coverage information, updating registration when patient's information changes. Develops and maintains good working relationships with other hospital personnel, community health, welfare and social agencies. Must have full knowledge and ability to access and assign ICD-10-CM and CPT codes for proper diagnosis and procedures. Maintains confidentiality of all information obtained during performance of job duties, as in accordance with HIPPA rules and regulations. Maintains a clean and well-organized work area.

OTHER DUTIES & RESPONSIBILITIES

Assists the Lead Utilization Review Coordinator (director) and other members of Case Management, in evaluating the patient's insurance coverage and proposed procedure for the appropriate care setting, contacts insurance for authorization of procedure, outpatient or inpatient hospitalizations, and/or swing bed level of care to include, but not limited to, ambulance transfers, etc. Hold and/or attend meetings Case Management Director's place, as appropriate and needed. Other duties and responsibilities as directed by the Case Management Director.

MINIMUM QUALIFICATIONS

(EDUCATION, EXPERIENCE, SKILLS, ABILITIES): Previous clinical background preferred. Thorough knowledge of medical terminology, clinical, and surgical data interpretation, medical coding, and health care billing and authorization is required Knowledge base of various computer software and use of computers, including keyboarding/typing skills required (i.e. Microsoft Outlook, Excel, and Word). Excellent communication skills, verbal and written are mandatory. Excellent customer service, problem-solving skills, prioritization, and organization are essential. Must display an ability to build positive relationships with medical staff. Ability to be thorough, pay close attention to detail, and follow detailed instructions with good time management skills. Previous experience in appointment scheduling in a health care environment is required (e.g., physician office, clinic or hospital) Experience in customer service is very desirable Must be able to meet tight time frames and have excellent customer service skills

PHYSICAL DEMANDS

May remain seated for extended periods of time. Use of telephone for long periods of time (earpiece available for use). Some walking required for reviews and errands throughout facility; bending, stretching, and/or lifting may be required. Ability to use hands for typing, taking notes, and messages is required. Interactions with patients and their caregivers/family members will occur.

WORK ENVIRONMENT

Well lighted, ventilated, and climate -controlled area within the hospital. Shared office space with other case management personnel.