Case Management (CM) is an organized program that relies upon professional, clinical and/or nursing expertise and critical thinking
skills to ensure safe, appropriate and fiscally responsible access, throughput and transition within and across the continuum of
care. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of
resources balanced with the patient?s right to self-determination. The CM functions include utilization review, patient advocacy,
resource management, continuum of care management, transitions of care and clinical documentation management. Staff will
provide information and guidance to the patient and/or family promoting improved self-management, and enhanced patientpractitioner
communication. A Geriatric Psych case manager is an autonomous role that will coordinate, negotiate and collaborate
with the patient/family and the interdisciplinary team (both internal and external) in a patient and family centered model of
care. Staff will ensure compliance with the hospital?s UR Plan, demonstrating expertise in denial prevention/management. The
Geriatric Psych Case Manager will be responsible for coordinating all interventions/outcomes provided by the Care Management
\u2022 1. Advocacy and Education
\u2022 1.1. Customer Service
1.2. Serves as a resource and provides education to patients, physicians and professional staff on levels of care, quality of
care issues and regulatory requirements
\u2022 1.3. Ethics and/or Risk Management identification and referral. Serves on hospital committees as appropriate.
\u2022 2. Clinical Care Coordination/Facilitation
2.1. Plan of Care and Outcomes Management. Facilitate coordination, communication and collaboration on behalf of the
patient/family, physician and payer to achieve goals and maximize positive patient health outcomes. Patient Integration;
ensure that each patient is the center around which all care decisions, plans of care and interventions are focused.
\u2022 2.2. Patient/Family Care Conferences
\u2022 2.3. Interdisciplinary Care Communication and Coordination. Actively participates in Interdisciplinary Patient Care Rounds.
\u2022 2.4. Clinical Resource Management; outcomes oriented, data driven, minimizes post acute fixes
\u2022 3. Continuity Transition Management
\u2022 3.1. Ensure patient movement along the acute care continuum (Access, Throughput and Transition).
3.2. Discharge Planning; serve as a consultant and educator to patient and family to explore the most appropriate setting to
safely meet identified needs. Ensure patient/family are informed of service providers (i.e. HHA's, DME's, Hospice and long
term care facilities) capable of providing for their post acute care needs, and all real or potential fees associated with such
services. Ensure that patient 'choice' is offered and obtained and documented.
\u2022 3.3. Advance Directives, Palliative/End of Life Care Referrals
\u2022 3.4. Community Resource Coordination (outpatient Cardio-pulmonary rehab, meals, elder/mental health services, 'other')
\u2022 4. Financial Management
\u2022 4.1. Acts as a resource for clinical documentation management outcomes oriented.
\u2022 4.2. Healthcare clinical resource management - clinical cost efficiency
\u2022 4.3. Coordination of patient benefits. Financial assistance referrals.
\u2022 4.4. Appeals Management. Compliance with Medicare's discharge notice/appeal.
\u2022 5. Performance & Outcomes Management (Clinical Resource Management)
5.1. Federal, State, Local, Regulatory agency compliance. Actively participate in the hospital's Utilization Review Committee.
DNV (IOS 9001), RI UR Regs, patient safety and quality core measures
\u2022 5.2. Clinical guidelines, evidence based practice
Qualifications - Case Manager - Requisition: 8538
May 17, 2019 Page 1
\u2022 5.3. Quality Improvement Practice Standards
\u2022 5.4. Organizational Performance Improvement/Management; LOS, Cost per Case, Denial Management
\u2022 6. Psychosocial Management
6.1. Counseling Support and Referrals: Substance Abuse, ETOH/Drugs, Adult/Child/Domestic/Elder abuse identification and
\u2022 6.2. Crisis Intervention; emotional stability, coping, grief and bereavement
6.3. Psychosocial Assessment and Functioning. Completes (or assists in the completion of) Mental Health screens (as
mandated by state regulations) for patients transferring to skilled nursing facilities.
\u2022 6.4. Health Wellness Promotion
\u2022 7. Research & Practice Management
\u2022 7.1. Application of Evidenced Based Practice.
\u2022 7.2. Will monitor and evaluate the effectiveness of case management interventions.
\u2022 7.3. Work proactively with management to modify practice patterns in an effort to attain a continuous cycle for improvement.
7.4. Case Management Best Practices. Professional standards; collaboration, communication, facilitation, coordination,
advocacy, resource management, accountability, professionalism.
\u2022 8. Utilization Management
\u2022 8.1. Adheres to State UR Regs and Third Party Payer contractual arrangements.
8.2. Application of medical necessity; intensity of service, severity of illness and discharge screening criteria. Level of care
appropriateness; admission status determination.
\u2022 8.3. Avoidable day identification and tracking
\u2022 8.4. Clinical Denial Prevention
Bachelors Degree (or higher) in the healthcare field preferred Cerification in Case Management desirable.
3-5 years of recent experience in hospital setting preferred Knowledge of utilization management, case management and
discharge planning preferred Experience in home health, hospice or public health and computer data management preferred
Familiar with community resources and managed care organizations preferred
Must hold a valid Rhode Island Nursing License CPI training within 1 yr of employment
Critical thinking, teamwork, creative problem solving, self directed, skilled negotiator, Knowledge of current utilization
management principles, PRO criteria and standards, discharge planning processes. Commits to continuous learning and strives to
improve competence in all areas of practice Advances knowledge of the profession through research and application of best
practice. Adheres to professional standards of practice and his/her professional code of ethics.
Credentials Included From Job
Credential Credential Source Essential
REGISTERED NURSE State of CT Yes
Qualifications - Case Manager - Requisition: 8538
May 17, 2019 Page 2
2:28:06 PMee Job Description