This case manager is responsible for the development, planning, coordination, and administration of functions including activities such as utilization review, discharge planning, social services and resource management, including daily review of medical records to determine appropriateness and medical necessity of admissions, continued hospital stay, and use of ancillary services.
The Case Manager collaborates with the Outcomes and Patient Flow Manager and uses knowledge of pathophysiology, pharmacology, and clinical care processes to participate with other clinical staff and physicians in the development of care standards and guidelines for the purpose of improving quality of care, changing practice, and reducing costs.
The RN Transitional Care Case Manager utilizes research findings in practice and participates in Transitional Care program design, implementation and evaluation and participates in ongoing quality improvement activities and collects clinical path variance data that indicates potential areas for system wide improvement of cares and services provides identifying errors and discrepancies in care that negatively impact the patient and seeks to rectify them through a broader system approach.
Evaluates and coordinates medical and rehabilitative services using cost containment strategies. Plans a proactive course of action to address issues presented to enhance the injured employees short and long-term outcomes.
Work telephonically and in the field with patients identified as high risk to identify needs, set goals and implement action steps towards achieving goals. Empower patients to help them improve their quality of life.
Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes.
The Outcomes Manager has the authority and responsibility for providing leadership by delegating appropriately and providing supervision to case managers and inpatient social workers within his/her assigned clinical practice group.
The Care Coordinator works collaboratively with all members of the multi disciplinary team to ensure patient needs are met and care delivery is coordinated across the continuum, as well as appropriately reimbursed by payers as contracted.
Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes.