The case manager is a licensed professional who coordinates and facilitates the ongoing care and appropriate discharge plan of a specific caseload of patients through the continuum of care. The case manager collaborates with members of the health care team, the patient, and their family to assure effective, efficient, and appropriate care and outcomes. Fiscal responsibilities include management of utilization, providing clinical information to payors and assuring appropriate reimbursement.
Essential Job Outcomes & Functions
The case manager independently manages a specific case load of patients as identified by the Resource Management Department and CareLines. The case manager analyzes patient information and assess each patient’s functional status and decision making ability in relation to the continuum of care and discharge needs. The case manager collaborates with the health care team, patient, and family in planning and facilitating the achievement of expected outcomes for patients. Each treatment plan is evaluated for appropriate quality outcomes and utilization of resources.
Continuum of Care/Quality
The case manager works collaboratively with the health care team to provide education, resources, and referrals as needed for each patient and their family or care taker. The case manager facilitates coordination among health care professionals, services, and settings involved in the patient’s care, with a focus on enhancing patient satisfaction. The case manager actively communicates with nursing leadership, CareLine physician directors, and Medical Directors on quality issues. As appropriate, concerns are referred to various Medical Staff Committees and CareLines through required documentation, including but not limited to the Clinical Pertinence Review Form. The case manager has the responsibility to maintain professionalism and provide ongoing education to the health care team regarding the case manager’s role.
The case manager works collaboratively and proactively with payors in managing patient resources. The case manager assures the hospital receives appropriate reimbursement through collaboration with the health care team and provides timely clinical review, as well as, retroactive review for unbilled accounts. The case manager utilizes the billing system to analyze charges vs. reimbursement and contract information. This information is used to structure the health care team toward effective utilization of resources. The case manager incorporates knowledge of medical necessity, CareLine protocols, and MAPs to evaluate for appropriateness of admissions, continued stay, and discharges. The case manager refers cases, as appropriate, for review to the Combined Resource Management Committee and other Medical Staff Committees as needed.