Inpatient Case Manager presso Cherokee Nation

The Inpatient Case Manager (ICM) will be responsible for all aspects of Case Management for an assigned group of inpatients to determine the appropriateness of the admission and continued stay. Assists in the development of the Plan of Care and ensures that the plans are implemented in a timely basis and determines the expected length of stay (ELOS). The ICM works collaboratively with Providers, Social Workers, Nurses, Home Health Care Services, and other members of the interdisciplinary team. The ICM actively participates in specific initiatives focused on reducing the length of stay (LOS), improved efficiency, quality, and resource utilization. Assignment will be by units/service and may encompass responsibility on other units/services.

Routine duties shall include providing health care services to individuals eligible for services in accordance with the self-governance compact and funding agreement between the Cherokee Nation and the United States executed under the authority of the Indian Self-Determination and Education Assistance Act. Practices only within the boundaries of competence, based on documented education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Patient Clinical Review. Reviews all admissions to identify patients where utilization review, discharge planning, and /or case management will be needed using standardized criteria to achieve optimal patient outcomes and appropriate reimbursement for the organization. Performs continued stay reviews utilizing standardized criteria to justify continued inpatient stay. Collaborates with the provider and other clinicians to expedite diagnostic testing and treatment. Documents all clinical reviews. Supports the mission, vision, philosophy, and goals of Cherokee Nation Health Services. Promotes an environment that is sensitive to cultural diversity and is open and responsive to the diverse backgrounds and experience of others. Case Management- the ICM process will include but not limited to: Collects information on the patient’s clinical, psychosocial, and functional status and reports to the interdisciplinary team. Identifies and documents variances affecting the LOS and the discharge planning process. Conducts follow-up of delays in treatment or reporting of results. Plans/develops specific goals with the interdisciplinary team and the patient and/or family. Implements and coordinates specific activities, strategies, and interventions to move the patient through the continuum of care. Documents outcomes achieved and identified internal and external barriers. Acts as a liaison and collaborates with interdisciplinary team on strategies to reduce readmission rate. Identifies and refers cases to the Physician Advisor in an effort to support timely progression of patients along the continuum of care and (appropriate) discharge planning. Interacts with the patient/family/caregiver to discuss Plan of Care and coordination of services based on clinical needs and available resources. Utilization Review (UR) Maintains a working knowledge of UR requirements of each third party payer within the patient population regardless of payer source. Provides clinical information requested as needed by the insurance companies as part of concurrent review in accordance to criteria guidelines whenever Pre-certification nurse not available. Provides education as needed to the providers, nurses, and allied health regarding current clinical interventions and rationale for treatments, and/or continued stays. Works collaboratively with the Pre-certification Nurse, providers, and third party payers on denial appeals. Communicates clinical information to the payer as needed, coordinating direct communication between third party payer and provider for peer to peer review as required. Discharge Planning. Assess, communicates, and monitors discharge planning process. Collaborates with Discharge Planner for discharge services. Assess clinical readiness for discharge at admission and coordinates services with Interdisciplinary team. Acts as liaisons with Pre-certification Nurse for current third party payer source. Collaborates and participates in the appeals process with all members of the Interdisciplinary team. Reporting Relationships. Reports to the Utilization Review Manager, Utilization Management Committee, and Discharge Planning Committee as required. Maintains verifiable records at an institution or facility that has a published records retention policy that is equal to or exceeds the retention required by federal, tribal and/or state regulations. Maintains the confidentiality of any information received from any person or source about a client, unless authorized in writing by the client or required by law or court order. Complies with the applicable state, tribal, and federal regulations in regard to the security, safety and confidentiality of any record they create, maintain, transfer or destroy, whether the record is written, taped, computerized or stored in any other medium. Provides Cherokee Nation Human Resources with a copy of current licensures, certifications, renewal of licensures and certifications upon receipt thereof.

SUPERVISORY RESPONSIBILITIES   

This job has no supervisory responsibilities.

EDUCATIONAL REQUIREMENT 

Has completed the basic professional curricula of a state board-approved registered nursing education program conducted in a member board jurisdiction that meets the requirements of the Oklahoma Board of Nursing, and holds or is entitled to hold a diploma or degree therefrom.

EXPERIENCE REQUIREMENTS

At least one year experience as a Registered Nurse or Case Manager.

COMPUTER SKILLS

An individual should have knowledge of Internet, Spreadsheet, and Word Processing software.

CERTIFICATES, LICENSES, REGISTRATIONS 

Possess and maintain an Oklahoma Board of Nursing Approved License. Must possess a valid driver’s license with a driving history verified through a motor vehicle report that meets requirements for Cherokee Nation underwriting rating. Possess and maintains Basic Life Support (BLS) Certification.

OTHER SKILLS AND ABILITIES 

Demonstrated ability in the areas of interpersonal relations, critical thinking, problem solving, and conflict resolution. Ability to effectively present data and information.

OTHER QUALIFICATIONS

Employee must not and will not be under sanction by the United States Department of Health and Human Services Office of the Inspector General (OIG) or by the General Services Administration (GSA) or listed on the OIG’s Cumulative Sanction Report, or the GSA’s List of Excluded Providers, or listed on the OIG’s List of Excluded Individuals/Entities (LEIE).

Must meet and maintain pre-employment and periodic background investigation and adjudication for child care. Ability to assess patient status. Effectively communicates and possess interpersonal skills. Supports the mission, vision, and philosophy of Cherokee Nation Health Services.

PHYSICAL DEMANDS 

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to walk; sit; use hands to finger, handle, or feel and reach with hands and arms. The employee is occasionally required to stand; climb or balance; stoop, kneel, crouch, or crawl and taste or smell. The employee must occasionally lift and/or move up to 50 pounds.

WORK ENVIRONMENT

The noise level in the work environment is usually moderate.