About The Role

Case Management- RN- 1834Essential Values-Based, Leadership and Management Competencies

Demonstrates competencies in line with the five core values that are the foundation of all activities performed by employees in order to achieve the Mission of Artesia General Hospital

Servant Leadership – Leading by serving others with compassion and humility.
Excellence – Striving for the highest quality in all we do.
Respect – Treating everyone with dignity and kindness

.• Virtuousness – Acting with honesty, integrity, and accountability.

Innovation – Embracing new ideas to improve care and outcomes.
Community – Fostering collaboration to meet the needs of those we serve.
Education – Promoting learning and professional development.

ESSENTIAL FUNCTIONS

Directs the daily operations of case management, utilization management, discharge planning, social services, and care transitions.
Establishes department goals, workflows, performance expectations, and accountability measures.
Provides supervision, coaching, education, and performance evaluation for case management and social services staff.
Ensures adequate coverage for utilization review, discharge planning, payer communication, and high- risk patient needs.

Determines Patient medical eligibility, qualifying diagnosis, and determines Medicare/Managed Care eligibility based on skilled services provided

Develops, reviews, and maintains departmental policies and procedures.
Promotes effective communication and collaboration among case management staff, nursing, physicians, ancillary departments, and hospital leadership.
Assists with departmental budgeting, staffing, productivity, and resource allocation.

Identifies and plans strategies to reduce in-patient length of stay and resource consumption.
Provides patient/ family with information about home health care, skilled nursing facilities, rehabilitation facilities and appropriate providers.
Maintains availability to the patient/family as a resource to facilitate communication among providers and to monitor services rendered.
.

UTILIZATION MANAGEMENT and MCG

Oversees the consistent and appropriate application of MCG guidelines for admission, level-of-care, continued-stay, and discharge-readiness reviews.

Ensures MCG criteria are used as a clinical decision-support tool and not as a substitute for physician judgment, applicable regulations, payer requirements, or the patient’s individual clinical circumstances.

Reviews inpatient, observation, and outpatient cases to support appropriate patient-status recommendations.

Ensures timely initial and concurrent reviews, payer notifications, authorizations, and clinical updates.

Escalates cases that do not clearly meet MCG criteria or require additional physician documentation.

Collaborates with attending physicians and hospital leadership regarding inpatient versus observation status.

Facilitates secondary physician review or physician-advisor review when medical necessity or patient status remains unclear.

Supports compliance with the Medicare Two-Midnight Rule and other applicable CMS patient-status requirements.

Ensures required Medicare notices are delivered accurately and timely, including the Medicare Outpatient Observation Notice and other applicable beneficiary notices.

Monitors the use of MCG and identifies educational needs, inconsistent application, and workflow gaps.

Maintains staff competency in the hospital’s current licensed MCG content and documentation requirements.

PATIENT STATUS and MEDICAL NECESSITY

Reviews admissions and continued stays for medical necessity, intensity of service, severity of illness, and appropriate level of care.

Identifies cases at risk for incorrect status, noncoverage, delayed authorization, or denial.

Communicates medical-necessity concerns promptly to physicians and appropriate hospital leaders.

Facilitates status changes when supported by the patient’s clinical condition, physician order, regulatory requirements, and hospital policy.

Monitors short inpatient stays, extended observation stays, avoidable admissions, and potentially preventable readmissions.

Ensures that patient-status determinations and changes are properly documented and supported in the medical record.

Collaborates with health information management, clinical documentation integrity, patient financial services, and revenue-cycle staff to improve documentation and reimbursement integrity.

DISCHARGE PLANNING and CARE COORDINATION

Ensures discharge planning begins at admission and is reassessed throughout the hospitalization.

Oversees the completion of initial assessments and the identification of medical, psychosocial, financial, functional, behavioral, and post-acute care needs.

Leads interdisciplinary efforts to develop safe, timely, and patient-centered discharge plans.

Coordinates placement and services involving skilled nursing facilities, rehabilitation facilities, long-term acute-care hospitals, home health, hospice, durable medical equipment, behavioral health, transportation, and community resources.

Ensures patients and families are actively involved in discharge planning and receive understandable information regarding available options.

Addresses barriers that delay discharge, including placement, transportation, medication access, insurance authorization, housing, caregiver availability, and equipment needs.

Facilitates complex case conferences and multidisciplinary care-planning meetings.

Supports safe transitions of care and communication with post-acute providers and primary-care clinicians.

Works to reduce avoidable readmissions and prevent gaps in care following discharge.

LENGTH of STAY and THROUGHPUT

Participates in or leads daily interdisciplinary patient progression and discharge-planning rounds.
Reviews each patient’s expected date of discharge, barriers to progression, outstanding tests or consultations, and post-acute needs.
Identifies avoidable delays and escalates unresolved barriers to the appropriate leader or physician.
Collaborates with nursing, medical staff, ancillary departments, and hospital leadership to improve patient flow.
Monitors observation length of stay, inpatient length of stay, avoidable days, discharge order-to-departure time, and delayed discharges.
Develops corrective action plans when performance does not meet organizational goals.

DENIAL PREVENTION and MANAGEMENT

Oversees the identification, tracking, review, and response to clinical and medical-necessity denials.
Ensures payer requests for clinical information are completed accurately and within required time frames.
Coordinates peer-to-peer reviews, reconsiderations, and appeals with physicians, payers, and revenue-cycle staff.
Performs root-cause analysis of denials and develops strategies to prevent recurrence.
Educates physicians and staff regarding documentation patterns that contribute to denials or payment risk.
Tracks denial trends by payer, reason, provider, service line, patient status, and financial impact.
Collaborates with finance and revenue-cycle leadership to improve authorization processes and reduce preventable write-offs.

REGULATORY and ACCREDITATION COMPLIANCE

Maintains compliance with applicable CMS Conditions of Participation, Medicare requirements, state and federal regulations, hospital policies, and accreditation standards.
Supports compliance with patient-choice, discharge-planning, beneficiary-notification, and utilization-review requirements.
Participates in the hospital’s Utilization Review Committee and prepares required utilization data and case reviews.
Maintains confidentiality and complies with HIPAA and other patient-privacy requirements.
Ensures department records, case reviews, notices, and supporting documentation are complete and audit-ready.
Participates in regulatory surveys, payer audits, internal audits, and corrective-action planning.
Maintains current knowledge of changes in reimbursement, utilization management, discharge planning, and payer requirements.