MicroNet Template

Case Manager Lead

OSS Health
Job Description
JOB TITLE:  Case Manager Lead
FLSA STATUS: Non-Exempt         DEPARTMENT: Case Management
REPORTS TO: CNO                       VERSION: 02/2019

The Case Manager Lead provides education and oversight for case management processes, technology and standard work.  Collaborates and serves as an expert resource for case managers and other clinical departments. The overall goal of the position is to enhance the quality of patient management and satisfaction, through the oversight of the case management team promoting continuity of care and cost effectiveness through the integrating and functions of case management, utilization review and management and discharge planning.  Has oversight and accountability for the care coordination and discharge planning of all patients.  Serves as a liaison between the case management team and the patient, physician, hospital and community resources or facilities for the exchange of information.  The Case Manager Lead also functions as a Case Manager
  • Associate’s Degree in Nursing from an Accredited Nursing School required. Bachelor’s degree in Nursing or Graduate from an Accredited Nursing School preferred.
  • Current license and registered as a professional nurse in the State of Pennsylvania.
  • Maintains continuous requirements for maintaining current Nursing License.
  • CPR certification required. 
  • Three (3) years of RN experience required, two (2) years of experience in Utilization Review (UR), Case Management, or related area preferred; leadership or management experience preferred
  • Must possess thorough clinical knowledge of disease process.
  • Knowledge of relevant laws, regulations, and safety requirements and standards required.
  • Knowledge of case management procedures and techniques, tools and responses required to ensure optimal patient care.
  • Skilled in communicating in a clear and concise manner with staff and physicians to ensure the proper pathway of care for patients.
  • Skilled in evaluating cases and determining appropriate care and status.
  • Must have the ability to read, analyze, assess, and use organizational data to educate other professionals and improve and implement case management processes.
  • Must have the ability to develop and meet department and organizational goals. 
  • Must have the ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
  • Must have effective organizational, time management and problem solving skills.  Must be able to work on multiple projects at one time.
  • Must have proficient computer skills.
  • Supports case managers on a daily basis, keeping abreast of difficult/complex cases, and coaching , guiding, and assisting as necessary.
  • Provides assistance/support with direct patient care issues – removes barriers for discharges, troubleshoots/ problem solves with case managers regarding DME/MD/family issues etc.
  • Provides analysis and feedback on process improvement activities and develops and presents focused educational programs for staff, both individually and in group settings.
  • Partners with leadership team on community and hospital wide initiatives focused on reducing length of stay and increasing safe discharges.
  • Collaborates in ongoing re-design and re-engineering of Case Management functions, to meet the changing needs and priorities of the organization as well as Medicare Conditions of Participation.
  • Ensures case manager compliance with state, federal, and contract payer rules, including Medicare Conditions of Participation.
  • Attends, directs as needed and follows up on issues from care coordination rounds with case managers and/or Physicians.
  • Participates in daily flow meetings, to provide feedback, assess need for resources based on throughput and speak to patient, physician or case management barriers to discharge.
  • Maintains confidentiality and protects sensitive data at all times, including patient information, proprietary information and personnel information.
  • Provides guidance/support to department on-boarding regarding the training needs of new case management team members.
  • Monitors and adjusts patients’ status based on changes in conditions and criteria.
  • Reviews all patients upon admission and daily during their stay utilizing nationally established recognized criteria.
  • Conducts concurrent medical record review using specific indicators and national clinical criteria approved by medical staff, and hospital administration.
  • Acts as patient advocate by reporting adverse occurrences.
  • Conducts review for appropriate utilization of services from admission through discharge following clinically accepted criteria.  
  • Communicates with physicians throughout hospitalization and develops an effective working relationship.  Assists physicians in desired patient outcomes.
  • Regularly accompanies physicians on rounds to identify/resolve problems/issues.
  • Coordinates/facilitates patient/family education.
  • Documents accurately and completely pertinent assessments, interventions, and outcomes for patients in accordance with the documentation standards, policies, procedures, and/or guidelines.
  • Assist Patients and families in making informed decisions by acting as their advocate regarding clinical status and treatment options. 
  • Participates in ongoing educational activities through in-services, education days, self-study, or established educational programs.
  • Maintains confidentiality of patient information.
  • Participates in quality improvement initiatives.
  • Practices principles of safety and infection control as defined by policy.
  • Facilitates communication and teamwork between departments, health care workers, patients and families
  • Responds to payers requesting additional clinical information to continue, validate or change authorization for services rendered.
  • Responds to denials for clinical services rendered by authoring appeal letter or engaging in a telephone call with payor followed up with a confirmation of call and outcome.
  • Performs related duties as assigned
Supervises Case Managers and Case Management Assistant
Must be proficient in the English language, both verbally and written, to communicate effectively with patients, families, co-workers, physicians, vendors, payers and federal agencies.
Long periods of standing and or sitting. May require bending and stooping. Fine and gross motor skills and manual dexterity to operate keyboard and other equipment. Frequently works under pressure to meet deadlines or deal with problem situations. Must be able to respond quickly and effectively to an emergency.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Climate controlled environment with occasional periods of being outside. Exposed to blood borne pathogens, odorous chemicals and specimens, toxic chemicals, electrical and mechanical hazards, confused or combative patients, bio-contaminated waste, and unpleasant elements. Subject to stressful situations, long or irregular hours.
Contact Information