Psychiatry Clinical Case Manager

Location

Springfield, IL | United States

Job description

The Clinical Case Manager - Psychiatry reports to the Director of Clinical Operations, Department of Psychiatry. The Case Manager performs utilization review, discharge planning, and case coordination mobilizing appropriate internal and external resources in order to achieve optimum value for both the patient and the reimbursement source. The Case Manager is an active member of a clinical patient care team, contributes to team goal setting, program development, quality improvement activities, and group outcomes. The Case Manager provides clinical expertise, problem identification and data collection for quality improvement initiatives. The Case Manager provides age-appropriate assessments, interpretation of data, and delivery of interventions.

Education:

• Bachelor’s degree preferred.

Licensure/Certification/Registry:

• Licensed as a Registered Nurse 

Experience:

• Minimum 3 years clinical experience in acute care required (additional home health and/or case management experience preferred).

Other Knowledge/Skills/Abilities:

• Demonstrated adaptability to changes in health care environment with proactive problem solving attitudes.
• Demonstrated ability to communicate complex ideas and data to support improvement process.

Clinical Case Coordination:

• Responsible to direct and facilitate movement of medical services along the continuum of care, working in collaboration with a multi-disciplinary team to establish a plan of care that will provide medically appropriate, high quality, efficient care for the patient . Documents in patient’s medical record to indicate interdisciplinary plan of care.
• Assess family dynamics and how they may impact patient outcomes. Educates patients/families and healthcare providers regarding utilization issues and discharge options. Collaborates with health care team to ensure that discharge needs are assessed for patients of all ages, and that an appropriate plan is developed/ implemented in a timely manner.
• Monitors patient length of stay and collaborates with physician and between physicians to ensure resource utilization remains within covered benefit entitlements, and are appropriate in relationship to the patient’s clinical and psychosocial needs.
• Provides clinical consultation and education to physicians, multi-disciplinary team, and other healthcare professionals. Participates in clinical quality improvement by identifying problems and/or opportunities for improvement in clinical outcomes, utilization of resources, concurrent data collection for potentially avoidable days, delays in service and quality improvement initiatives.
• Participates in quality improvement and program planning. ). Participates in Unit Based Council (UBC), including team goal setting program development, clinical system process improvement, and achievement of desired team outcomes.

Utilization Management

• Review prospectively/concurrently/retrospectively all inpatients for appropriateness of admission, appropriate level of care, and determine appropriate length of stay based on established criteria. Apply appropriate intervention when case fails to meet criteria. Provide consultation to physicians/healthcare professionals to assist with criteria based decisions. Assists with appeals process by providing timely input regarding case specific details and information.
• Communicates case management/utilization management activities with external review agencies within agreed upon time frame. Monitors patient length of stay and collaborates with physician to ensure resource utilization remains within covered benefit entitlementsE3. Home Care Referrals
• Assist in establishing a definitive home care plan prior to discharge, including assessment of the appropriateness of the requested services, medical supplies, and appliances; provide explanation of coverage of desired services and of services available under insurance plan. Collects necessary demographic data, completes clinical assessment of patient needs, and identifies system resources to meet patient needs.
• Interacts with patient/family/caregiver to develop a care plan to include identification of resources necessary to meet patient needs. Updates patient, patient’s family, patient care team, payer and provider/vendor of changes in discharge plan.
• Utilizes clinical skills to obtain authorization/certification of plan by third party payers when necessary.

Facility Transfers

• Assist in establishing a definitive transfer plan prior to discharge, including assessment of the appropriateness of the requested services that may include acute care hospitals, acute rehab, state facilities, and extended care facilities.
• Interacts with patient/family/caregiver to develop a transfer plan, including transportation plan. Completes written plan for transfer and schedules services with appropriate entities.
• Collects necessary demographic data, completes clinical assessment of patient needs, and identifies system resources to meet patient needs.
• Utilizes clinical skills to obtain authorization/certification of plan by third party payers when necessary.

Management of Public Payor Requirements

• Identifies patients eligible for Public Payment.
• Communicates with contacts from payor offices.
• Processes necessary paperwork for coverage.
• Communicates with therapy and nursing staff regarding requirements for payment.
• Establishes discharge plan as required.
• Follows up on denials or requests for further information.
• Informs management of denial trends or unusual payor responses.
• Maintains current knowledge of payor system changes.

Other

• Maintains clinical knowledge base of regulations and specific protocols and processes.
• Performs all other duties as assigned or as necessitated.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform tasks other than those specifically presented in this description.

Job tags

Salary