0.2TE
Non-exempt
The Case Manager – MJ Social Worker PNE reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines, and all other regulatory and accreditation standards.
- Serves as primary liaison between the interdisciplinary team and the patient/caregiver, educates patient/caregiver on the continuum of care and facilitates discharge coordination. Follows the patients from admission to discharge. The case manager communicates to external payers on behalf of the patient. Acts in partnership with the attending physician to closely monitor utilization and LOS. Works with the patient/caregiver to plan and facilitate a timely and appropriate discharge plan.
Responsibilities:
- Handles caseload of patients as determined by manager
- Forwards assessments and clinical data to payers and external providers to facilitate transitions and payment
- Communicates team conference and POC recommendations to patient and family and to third parties as indicated
- Assists with facilitation of team conference to ensure that patient continues to meet LOC criteria and is progressing toward discharge goals in conjunction with interdisciplinary team.
- Works with interdisciplinary team on ensuring procurement of discharge needs for patient in terms of DME, clinical services and ongoing care to support a safe transition to an appropriate LOC
- Facilitates family training as needed to support a safe transition to the next LOC
- Assesses need for and provides referrals to community resources to support the patient safely in the community setting
- Coordinates with patient/financial services and admissions to ensure smooth transitions between levels of care and manage concurrent denials
- Provides ongoing education to interdisciplinary team on patient’s insurance benefits and status of LOS approval
- Requests authorization for continued stay from payers as recommended by interdisciplinary team through concurrent review process. Coordinates appeals on any concurrent denials of requests for continued stay.
- Reviews patients progress and medical necessity for continued stay against protocol and benchmarks and communicates with attending physician and team
- Monitors and communicates resource utilization with attending physician
- Identifies variances from established benchmarks on cost/outcome/LOS and notify physician and team
- Obtains authorization as required from payer for any special services or procedures
- Case Managers in pediatrics assist with managing referrals for IRF and outpatient services as well as assists with referral development objectives
- Case Managers in Pediatrics facilitate return to school after discharge and home/hospital tutoring