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Participate in all phases of the Case Management Program (CMP) and ensure that the CMP meets established case management (CM) standards of care.
Provide nursing expertise about the CM process, including assessment, planning, implementation, coordination, and monitoring.
Identify opportunities for CM and identify and integrate local CM processes.
Develop and implement local strategies using inpatient, outpatient, onsite and telephonic CM
Develop and implement tools to support case management, such as those used for patient identification and patient assessment, clinical practice guidelines, algorithms, CM software, and databases for community resources.
Integrate CM and utilization management (UM) and integrating nursing case management with social work case management.
Maintain liaison with appropriate community agencies and organizations.
Accurately collect and document patient care data.
Develop treatment plans including preventive, therapeutic, rehabilitative, psychosocial, and clinical interventions to ensure continuity of care toward the goal of optimal wellness.
Establish mechanisms to ensure proper implementation of patient treatment plan and followup post discharge in ambulatory and community health care settings.
Provide appropriate health care instruction to patient and/or caregivers based on identified learning needs
Degree:
Associates Degree of Nursing
Education:
Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE) or as otherwise outlined
Experience:
Minimum of two (2) years recent experience within the last four (4) years in professional nursing.
Under Case Manager (CM) requires minimum of two (2) years recent experience (within the last four (4) years) in professional nursing or CM.
Under Utilization requires six (6) years of broad based clinical nursing experience and previous experience in UM is preferred.
Must possess the necessary knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines.
Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care.
The Contractor shall have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD- 9), and Current Procedural Terminology-Version 4 (CPT-4) coding.
Contractor personnel shall have a minimum of two (2) years of recent experience (within the last four (4) years) in nursing
Certification:
Possess one of the following certifications:
o Certification of Disability Management Specialists Commission: Certified Disability Management Specialist (CDMS)
o Association of Rehabilitation Nurses: Certified Rehabilitation Registered Nurse (CRRN)
o American Board for Occupational Health Nurses Certified Occupational Health Nurse (COHN) or Certified Occupational Health Nurse-Specialist (COHN-S).
o National Board for Certification in Continuity of Care: Advanced Certification in Continuity of Care (ACCC)
o Commission on Rehabilitation Counselor Certification: Certified Rehabilitation Counselor (CRC)
o American Nurses Credentialing Center Nurse Case Manager (RN-NCM)
o National Academy of Certified Care Managers: Care Manager Certified (CMC)
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