Summary:

The Case Manager will provide comprehensive Case Management for patients as assigned to include, but not limited to: assessing patient’s needs; developing, implementing, monitoring, and documenting the progress of the patient throughout their hospitalization in an outside area hospital to meet their care needs prior to discharge. The intensity of Case Management is situational and appropriately based on patient need. This position is accountable for the quality of clinical services provided by both them and others and identifies barriers which may hinder effective patient care. The Case Manager performs Utilization Review of the medical necessity and appropriateness of care using InterQual criteria of patients admitted to Gila River Health Care inpatient unit: assessing patient admissions and continued stay criteria to identify issues that may delay patient discharge and facilitate resolution of these issues.

Critical Tasks:

Demonstrates a culture of kindness through all interactions whether verbal or non-verbal with all GRHC staff members, partner facilities staff and vendors.Manages and oversees assigned patient case load to ensure delivery of all covered services identified for continuity of care across all levels of care and involved providers to achieve the optimal clinical, financial, operational, and patient satisfaction outcomes.Maintains HIPAA standards of patient confidentiality during all interactions whether written, verbal, or electronic.Establishes and promotes a collaborative relationship with members of the healthcare team within GRHC and outside facility partners.Serves as Case Manager between referral hospitals, treatment facilities and patients/patient’s families to ensure delivery of effective and appropriate assistance and follow-up for returning to pre/post hospitalization status/care.Reviews charts of assigned patients to determine appropriate referral services based on assessed patient needs.Facilitates, schedules and/or participates in a variety of patient Case Management activities to ensure patient and/or family personal and health care needs are met in a timely manner; proactively identifies alternative resources as needed.Participates in “on-call” for Case Management Department and Utilization ReviewPerforms Utilization Review of patient chart to ensure compliance with established InterQual criteria to maximize reimbursement/coverage of charges.Evaluates inpatient medical necessity and appropriateness of care utilizing InterQual criteria, for optimizing outcomes.Assesses patient admissions and continued stay to identify issues that may delay patient discharge and communicates to the interdisciplinary team while facilitating a resolution.Collects and communicates pertinent, timely information to the health care team to fulfill utilization and regulatory requirements.Collaborates with patient, family members, and other involved parties to ensure care coverage through private and governmental health care plans.Collects outcome data to be used in identifying best practices and targeting performance improvement solutions.Participates in departmental orientation, on the job training, and quality assurance programs/initiatives.Receives and responds to patient concerns; research issues for corrective action as appropriate based on findings; escalates physician/provider concerns to appropriate parties and identifies alternative solutions.Participates in a variety of department and hospital educational programs to maintain current skill and competency levels; identifies and discusses performance or training needs with Supervisor.Participates in Community Events representing GRHC and Case Management Department with ability to educate on departmental functions.Other duties as assigned by Case Management Director/ManagerEstablishes goals and objectives for the department that meet or exceed GRHC’s Code of Ethics and Standards for Conduct Policy.Is familiar and remains current on safety and emergency management process for the department.

Required Qualifications:

Current State of Arizona or Compact State Registered Nurse license, BSN preferred.Current CPR for Healthcare professional's certificationMust have at least 1-year previous case management experience, CCM certification preferred but must obtain within 2 years of hire.Experience must include working in an acute care and/or home care setting for at least a 12-month period.Native American population preferred.Must have a working knowledge of Case Management, acute care and/or home care environments, community resources and resource/utilization management.Case Management Specialty Area Requirements:Pediatrics Case Manager – Must have at least 1 year Pediatrics experienceCancer Case Manager – Must have at least 1 year oncology/hospice/or cancer case management experiencePain Management Case Manager – Must have at least 1 year experience working with pain management patients/hospice  patients.Women’s Health/High Risk Pregnancy Case Manager – Must have at least 1 year Women’s Health/Pregnancy experienceFamily Medicine Case Manager – Must have at least 1 year Medical-Surgical or Family Clinic experienceInternal Medicine Case Manager - Must have at least 1 year Medical-Surgical or Family Clinic experienceEmergency Department/Utilization Review Case Manager – Must have 1 year Medical-Surgical experience and/or 1 year Utilization Review experience