The Access Care Manager works collaboratively with interdisciplinary and healthcare team members, both internal and external to the organization to facilitate patient care through effective utilization and monitoring of healthcare resources and assumes a leadership role to achieve safe clinical and financial outcomes. The Access Care Manager coordinates care and services through the acute care episode and across the continuum. The goal of this position is to control costs while monitoring the quality of patient care ensuring that care is being provided in the appropriate setting.  

1. Reviews electively scheduled procedural cases preoperatively to assure for authorization, assess if inpatient only, and assure patient status.
2. Serves as a case management liaison to Patient Access Services and Acute Care Coordination services. Collaborates with Patient Access to ensure capture of correct insurance and demographic information. Communicates proactively with insurers & payers to ensure reimbursement.
3. Obtains clinical data and conducts utilization review to determine medical necessity, appropriateness of inpatient admissions, and appropriateness of inpatient or outpatient procedures, lengths of stay and discharge plans. Refers cases to the appropriate Physician Advisor due to medical necessity, quality, or delay in service.
4. Evaluates scheduled surgical cases for NCDs (National Coverage Determinations) and LCDs (Local Coverage Determinations) which are decisions by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary. Works with physicians and their staff members to ensure patients meet medical criteria for NCDs and LCDs and if not, to assist in establishing the needed documentation to meet the established criteria.
5. Provides case management services to all areas of access to: SDC, PACU, Cath lab, Direct Admit, and Transfer patients.
6. Collaborates with PACU, and Cath lab staff on best practice guidelines. Supports improvement of physician documentation to reflect the level of services provided. Educates PACU, and Cath lab healthcare providers in understanding the role of the Access Case Manager/Coordinator. Determines accuracy of level of care designation at time of bed requests. Educates physicians and physician office staff regarding admission criteria.
7. Expectations to meet outcome measures which include but are not limited to:

• Staff & patient satisfaction
• Improved payer admission denials, and Recovery Audit Contractor findings
• Reduced patient status changes

8. Documents assessment, plan, and intervention in the electronic medical record to include: status determination; clinical and psychosocial factors that will impact patient transition or discharge; exiting services and supports; barriers; referrals and interventions; patient family education; coordination of services and an individualized plan.
9. Collects data and tracts clinical information to assist with process improvement.
10. Performs other duties as may be needed or assigned.
11. Demonstrates competence to perform assigned patient care responsibilities in a manner that meets the age-specific and developmental needs of patients served by the department.
12. Appropriately adapts assigned patient assessment, treatment and/or care methods to accommodate the unique physical, psychosocial, cultural, age-specific and other developmental needs of each patient served.
13. Supports DCH Health System mission, vision and values. Demonstrates established customer service behaviors and standards.  Treats all customers with courtesy, dignity, respect and professionalism

Supervision is received from the Manager of Utilization Management. Acts as preceptor/mentor for procedural

department staff. 

DCH Standards: 

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Mission, Vision, and Values including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

Current Alabama RN license required. BSN preferred. National certification (e.g. CCRN, RNC, CEN, CNOR, OCN, ANCC, CAN, CPAN, CFRN, etc.) in the related field is preferred.

Three years recent, full-time hospital experience preferred.  Work experience in case management, utilization review or hospital quality assurance experience is preferred. 

Completion of a Clinical Documentation Improvement Course preferred.

Maintains 24 documented hours of relevant continuing education related to licensure requirements. 50% of education should be related to role enhancement as a care transition nurse and clinical changes within the assigned area.

Skill in determining the needs of patients, correct interpretation and performance of physician's orders, thoroughness in documentation and proficiency in the performance of assigned duties is required.

Knowledge of managed care, governmental payers, and third party reimbursement.

Information systems including but not limited to MIDAS.

Skill in using Microsoft office applications.

Ability to exercise clinical judgment and autonomous decision making.

Strong interpersonal skills relative to both professional and lay interactions.

Strong organizational skills.

Demonstrated working knowledge of performance improvement activities.

Demonstrated working knowledge of data management/reporting practices.

Must have basic computer skills.  Must have skill and working knowledge of all equipment pertinent to the assigned area.  Working knowledge of the operation of personal computers and Microsoft Office software (Word, Access, Excel, and PowerPoint) is expected. Ability and skill to operate standard office equipment is expected.

Strong communication skills.

Must be able to read, write legibly, speak, and comprehend English.

The ability to read, write and/or speak Spanish is desirable.

The ability to demonstrate initiative, the capacity to “problem solve”, strong organizational skills and the ability to work interdependently in a fast-paced environment is highly desirable.

SCOPE, PURPOSE, AND FREQUENCY OF CONTACTS:

On-going contact with patient and families, medical-dental staff, social workers, nursing PI/Outcomes, and ancillary services.  Additional contact with home health care providers, durable medical equipment providers, insurance/managed care organizations and varied community resources.

WORK CONTEXT

• Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts.
• Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance.
• Ability to encourage and build mutual trust, respect, and cooperation among team members.
• Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources.
• Ability to work independently or within a team structure.
• May be exposed to environmental cleaning chemicals

PHYSICAL FACTORS

• Requires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.
• Ability to tolerate prolonged periods of sitting or standing and/or walking.
• Ability to reach reasonable distances to handle equipment.
• Good manual and finger dexterity.
• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential.

Required to work various shifts and to alternate days off