Job - RN-Coordinator Case Management-PICU

Children's Hospital of Philadelphia - Philadelphia, Pennsylvania

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RN-Coordinator Case Management-PICU

Children's Hospital of Philadelphia - Philadelphia - PA Careers Responsibilities

Under the general supervision of the Director, the Case Manager provides clinically-based support to the delivery of effective and efficient patient care. Paces each case from physiological and economic perspectives. Has overall accountability for the utilization management and transition management for patients within the assigned caseload. Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement. Uses criteria to confirm medical necessity for admission and continued stay. With the patient, family and health care team, creates a discharge plan appropriate to the patient’s needs and resources.  Must be willing to work occasional weekends and holidays.

Job Responsibilities

  Essential Duties and Responsibilities:
Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. Documents all case management internventions in the current electronic system (EPIC).
Validates admission and continuing stay criteria with third party payers as well as the Attending Physicians.  Recommends alternative care sites where appropriate.
Collaborates with third party payers to prevent denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent the denial when possible.
Supports the effective prevention and management of denials, including providing requested information as part of the appeal process.
Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual length of stay to initiate a plan for discharge.
Collaborates and communicates with patients/families related to reimbursement issues and to create a discharge plan. Supports the process of patient choice in establishing a discharge plan.
Uses clinical knowledge and knowledge of anticipate response to treatment to assess patient progression towards anticipated outcomes. Communicates and coordinates with the patient/family and health care team to intervene when progression is stalled or diverted.  Addresses actual/potential barriers to discharge
Completes the interventions necessary for discharges to home with self-care, home with services or short term skilled nursing facility placement. Assembles necessary referrals, discharge summaries and pertinent information for discharge to home,placement, or transfer prior to the day of discharge.
Actively contributes to, participates in, and follows through on interventions identified in care coordination and complex patient rounds.
Identifies high risk patients and creates a collaborative plan to address their unique needs.


Job Responsibilities (Continued)

Other Responsibilities:
Adheres to established departmental policies, procedures, and objectives.
Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards apprpriate to this position.
Demonstrates a courteous and professional manner through interactions with internal and external customers.
Integrates scientific principles and research based knowledge in decision making.
Exemplifies a professional image in appearance, manner and presentation.
Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
Reseraches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
Adapts behavior as needed to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style
Performs other related duties as assigned.


Job Responsibilities (Continued)



Required Licenses, Certifications, Registrations

RN - Registered Nurse


Required Education and Experience

Registered Nurse with a minimum of 3 years experience as clinical nurse in an acute care pediatric setting.


Preferred Education, Experience & Cert/Lic

BSN from an accredited program strongly preferred

Discharge planning or home care experience preferred

Prior experience as a Case Manager or Utilization Reviewer preferred.

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