Job Description

PURPOSE OF THE ROLE:

The role of the case manager is to ensure a smooth and wholesome patient safety centric approach from the point of admission of the patient up until discharge whilst ensuring the appropriate level of care is implemented in line with the plan of care. The role would also perform the necessary advocacy on the services and plans formulated during the stay whilst adhering to the insurance approvals and advocating the patients’ requirements to the respective hospital stakeholders.

ROLES & RESPONSIBILITIES:

Care Facilitation

• Assess all patients
• Clinical
• Psycho-social
• Economic-review financial coverage of all inpatients

Proactive Length of Stay Management

• Calculate LOS (for patient who transfer to acute, HDU or ICU from LTC or PAR or LTAC areas)
• Round daily with physicians, Charge Nurses, Social Workers, PAA, communicate LOS, discuss plan of care, clinical documentation, psychosocial issues/barriers, Utilization Review + Utilization Management issues, continuum of care facilitation, MDT coordination, plan for discharge, follow up community support, repatriation.

Utilization Management

• Confirm benefit coverage to avoid delays, each month for: LTC; PAR & LTAC patients
• Ensure appropriate treatment/intervention based on medical necessity and supported by physician documentation
• Diagnostic testing directly related to the admitting diagnosis
• Frequency of diagnostic testing
• Cost effective yet clinically appropriate selection of diagnostic testing

Utilization Review

• Medical Necessity – support physician decision making with evidence based admission, continued stay and discharge screening criteria
• Clinical liaison/interface, review criteria for admission and give recommendations

Plan for Discharge

• Have more than one plan underway to deal with a discharge
• Engage patients and families early in the planning process
• Facilitate and implement plan for transfer, repatriation, follow up

Clinical Documentation

• Facilitate accurate physician documentation which supports medical necessity of admission and resource utilization and accurately reflects severity of illness, risk of mortality to support justification to Payer for Authorization each month
• Outcome directly related to Case Mix Index
• Work with MDT team and facilitate MDT summary note

Plan of Care

• Facilitate and participate in Physician and MDT rounds and chart reviews, to identify any potential or real change in patient condition or treatment plan that would require modification to address the need for increased or reduced services at time of discharge.
• Ensure appropriate consults are in place and performed in a timely manner.
• Provide clinical information to payers as indicated for continued stay authorization.
• Collaborate with the Social Worker to Identify appropriate resources to provide post discharge care for those patients who are able to transition back to home.
• Communicate patient anticipated discharge plan and continuing care needs and services for those patients able to transition back to home.
• Review final discharge plan with patient/family and MDT Monitoring and Evaluation

Advocacy

• Promote the use of the most appropriate setting in meeting each patients needs to maximize quality of care, utilization of resources and insurance benefits.
• Promote patient and family rights to self-determination and involvement in care planning and goal setting.
• Collaborate with the Social Worker to Involve appropriate hospital and community resources, as needed, to address patients medical, ethical, financial, psychosocial and legal issues
• Coordination of school placement for Pediatric patients with families
• Entitlement assessments
• Patient advocacy and environmental interventions

EDUCATION AND EXPERIENCE:

• Bachelor’s or Master’s Degree in Nursing
• 2 years Clinical Nursing or Case Manager/Leadership Experience
• DOH License
• Commission for Case Manager Certification, or equivalent
• Fluent in written and oral Arabic language