LCMC Health Case Manager (QA) in New Orleans, Louisiana

Children’s Hospital of New Orleans, a leader in Pediatric care throughout the Southeast region, is currently seeking an RN Case Manager. The mission of making care available to all children has allowed Children’s to grow as an organization.

Children's Hospital is a 247-bed, not-for-profit medical center offering the most advanced pediatric care for children from birth to 21 years. With over 40 pediatric specialties and more than 400 physicians, it is the only full-service hospital exclusively for children in Louisiana and the Gulf South. We invite you to experience the magic of Children's Hospital.

Job Summary: The Case Manager collaborates with the interdisciplinary team to implement the plan of care and transition strategies, ensuring the achievement of desirable patient outcomes, appropriate length of stay, efficient utilization of resources, increased patient and family involvement, and patient/family/staff education. Implementation is accomplished through patient assessment, monitoring of the plan of care, review activities, coordination with the interdisciplinary team and any outside third-party payers, communicating with physicians, performing utilization management activities to avoid denials, reduce avoidable delays and control costs where possible, and by facilitating continuity of care across settings. Job Standard: Collaborates with the interdisciplinary team to facilitate care progression and transition to the level of care that meets current medical necessity and patient care needs.

Performance Expectations 1. Identifies anticipated discharge date at the time of admission in collaboration with the members of the health care team. 2. Ensures that the patient/family is aware of the plan of care and anticipated length of stay. 3. Monitors patient’s plan of care and progress in relation to anticipated length of stay and intervenes to facilitate a timely discharge. 4. Facilitates communication among team members to resolve issues that may impact the plan of care. 5. Encourages interventions appropriate to the reason for the patient’s admission. 6. Initiates referrals to the appropriate areas to expedite care, treatment, and services (SW, PT, speech therapy, financial counselor, palliative care, etc.) 7. Seeks information to understand alternatives to treatment plan from identified clinical resources to the department. 8. Identifies and documents avoidable delays in care and works collaboratively with the healthcare team to prevent them. 9. Escalates cases with unresolved issues according to department guidelines Job Standard: Leads and implements the transition planning process from the time of admission to discharge by effectively assessing patient/family needs, preferences, and available resources.

Additional Responsibiities: 1. Completes a discharge planning assessment for all patients in assigned case load within 24 hours of admission. 2. Confers with attending physician and other members of the health care team to identify needs. 3. Documents all pertinent information related to the discharge plan in the medical record. 4. Serves as a resource and advocate for patients/families by providing information regarding available resources appropriate for the patient’s discharge plan and third-party payer guidelines. 5. Communicates with patient/family to ensure understanding of anticipated discharge date and involvement in planning for care after discharge in a consistent and timely manner. 6. Refers cases with complex psychosocial and or medical issues that may create barriers to discharge to the social worker according to department guidelines. 7. Initiates referral to facilities and agencies that can meet the post hospital care needs of the patient and are authorized by third party payors. 8. Ensures patients’ right to choice in providers of post hospital care agencies and facilities that can meet the patient’s care needs. 9. Ensures continuity of care by acting as a liaison between the hospital and community resources. 10. Provides all required information to the agency/facility to facilitate a smooth transition. 11. Maintains positive working relationships with community agencies and facility staff to maximize access for patients/families. 12. Keeps up to date on available community resources and regulatory requirements that impact discharge planning. 13. Provides input to the development of processes that improve continuity, transitions, and patient centered care across the continuum of care.

Job Standards: Accountable for utilization management functions and communication with payers to assure authorization and reimbursement for hospital stay. Performance Expectations 1. Performs admission review within 24 hours of admission on all patients in case load utilizing InterQual Criteria to determine if patient meets medical necessity for admission. a. Initiates contact with attending physician to solicit additional information to support medical necessity for admission when there is not adequate information in the medical record. b. Suggests alternative level of care/treatment plan for patients not meeting medical necessity for admission. c. Refers cases for second level review that do not meet medical necessity or level of care requirements, according to department procedure. d. Documents review according to department procedure. e. Submits reviews to third party payors according to contract requirements in a timely manner. 2. Assures days are approved and information is entered in a timely manner. 3. Follows up with third party payors when there is a lack of response to request for authorization. 4. Advocates for the patient, family, physician, and facility to obtain benefits from third party payors and others that provide financial assistance. 5. Communicates with patients and families to ensure understanding of third-party payor guidelines. 6. Conducts continued stay review as indicated based on clinical condition and third-party payor requirements according to department procedure. 7. Collaboratively institutes prevention plans to avoid third party payor denials and problem solves with the health care team when denials are received. 8. Manages concurrent denial/appeal process in collaboration with the attending physician. 9. On a concurrent basis, assesses the appropriateness and timeliness of the level of care, diagnostic testing and clinical procedures, quality and clinical risk issues, and documentation completeness. 10. Acts collaboratively to resolve resource issues, keeping manager/director informed as needed.

Experience, Education, Licensure and Certifcations Requirements:

  • 3 to 5 years nursing experience in a clinical area; 3 years nursing experience and 2 years case management experience

  • BSN with current nursing licensure in LA; Certified Case Manager

  • Attends programs for certification in case management

  • Case management training

  • Utilization review/discharge planning functions

  • Hospital and CM software Case management certification, ACM or CCM

  • Advanced knowledge and use of hospital information systems

  • As a member of our team, you will not only experience personal reward, you will also find tangible benefits for you and your family. To apply on line please visit our website at www.chnola.org.

Children's Hospital is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, age, status as a protected veteran, or status as a qualified individual with disability.