The Care Management department provides several major services to assure a safe and efficient passage of patients through their acute hospitalization and transition to the next level of care.  Our goal is to balance individual clinical and psychosocial patient/family needs with the efficient and cost effective utilization of resources while promoting quality outcomes.

RN Case Managers provide a coordinated approach with in the interdisciplinary team in determining appropriateness of admission, continued stay in the hospital and planning for transition to various levels of care in the hospital, community and home. Intensity of service is dependent on individual patient needs as assessed by the case manager. Nurse Case Managers assure robust utilization review, resource management and discharge planning.

 

RN Care Managers assess patients on admission for available family support, insurance resources, and potential discharge planning needs. They use established criteria to determine appropriateness of admission and continuing stay and work with insurance companies to assure ongoing authorization for continued stay and post hospital needs.  Daily care coordination rounds occur on each nursing unit Monday through Friday at which Case Managers meet various disciplines to discuss the plan for the day and the plan for the patients stay. They will also frequently lead and/or be involved in multidisciplinary care conferences with family involving complicated care situations. They contribute to meeting OHSU’s strategic plan of safe LOS reduction and reduction in readmission rates.

 

Admit/ED Nurse Case Manager: In addition to the above basic CM functions, also provides the following –

• Assuring accurate patient status and admission order for pts entering via ED, and OR, 7 days per week
• Reviews ED Observation unit patients for meeting observation criteria and completes UR using established criteria.
• Round with NP in ED OBs by 10am.
• Effectively communicates reviews with Patient Placement Office.
• Follows up in collaboration with unit CM on admission status and completeness of Utilization review on admission.
• Performs discharge planning for patients in the Emergency department
• Assesses patients potential to DC from ED with community care coordination (PCP location, follow up appointments, medication assistance, SNF, long term care, DME, Memory or Foster care)
• Back up for weekend/EVE Case Managers.
• Follows current data tracking procedures
• Reviews transfer center patients and advise physicians on acceptance of potential transfers.
• Preforms Utilization Review for each patient admitted without a review during weekend hours using established medical necessity guidelines.
• Reviews order/classification discrepancies and take actions to resolve the discrepancy.
• Discusses cases with providers and Case Managers as needed, including attending physicians and escalation to the Care Management Physician Advisor when indicated.
• Assesses for and tracks potentially avoidable hospital days.
• Educates providers regarding documentation requirements that support medical necessity determinations.
• Delivers Condition Code 44 notices, Observation notices, and Medicare Important Messages in the absence of sufficient clerical support.
• Documents according to departmental policy.
• Leads the effort to assure compliance with CMS and other insurance regulations related to Utilization Review.

 

Evening Shift Case Manager

• Provide nurse case management support to patients, families and staff in the evening shift 7 days per week
• Assure hand over of information to day shift CM.
• Receives referrals from day shift CM’s
• Trouble shoots any SNF placement issues that occur after hours
• Root Cause Analysis for any failed SNF discharge
• Admit/ED Case Manager functions as needed

 

RN Case Managers are responsible to be aware of and comply with regulatory requirements of DNV, Medicaid, Medicare and Oregon Nurse Practice Act.

 

Department Specific Working Conditions:

Case Management is represented on every unit and the Emergency department.

The Care Management central resource office is located in 9A4.

Each Case Manager has an office with a work station near the unit they are assigned to.

Communication factors: Case Managers are available by pagers 7 days a week during the day. They are also available by telephone/voicemail and e-mail.

 

Department Specific Requirements (competencies, equipment, certifications, etc.):

Proficiency within the interdisciplinary team in leading daily discharge rounds, negotiating conflicts, coordinating patient goals between disciplines, communicating about and educating physicians on patient status decisions.
Ability to describe what utilization review criteria is and how it is utilized.

Proficiency with managing difficult and sensitive family and provider care conferences including: adjustment to new levels of function, end of life discussions, imbalance of available resources (social, spiritual, medical, financial).

Progressive leadership positions with in nursing unit – examples include:  Charge nurse, UBNPC Chair/Member, Shared Governance councils. 

• BSN Graduates: Baccalaureate Degree in Nursing from a program accredited by Commission of Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN) or Commission for Nursing Education Accreditation (CNEA) 30 days before start date.
• ADN Graduates: Associate Degree in Nursing from an accredited program 30 days before the start date.
• Associate degree Nurses required to enroll in BSN program within 3 years of hire and complete within 5 years of hire
• Current, unencumbered Oregon State Registered Nurse License
• BLS at time of hire and must be issued by the American Heart Association (AHA)
• BLS must not expire during orientation
• Must be able to perform the essential functions of the position with or without accommodation

Usual Orientation Time:  

• Experienced hospital based Nurse Case Manager 6-8 weeks       
• Experience in acute care but not Case Management 8-12 weeks     
• Resource                                                   8-12 weeks

 

Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or aaeo@ohsu.edu.