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d'cm's Latest Activity

  1. The best answers I have ever seen to this question can be found at : Nick Carmody JD, MS Psych (@Nick_Carmody)
  2. d'cm

    Is Case Management the right move?

    Insurance company CM would definitely reduce your exposure to Covid - but not to regulatory BS.
  3. d'cm

    New Nurse Case Manager

    It really depends on what population you will be working with. Insurance CM can be any number of different things e.g. Disease mgmt, inpatient your/DC planning, or LTC (MLTSS medicaid).
  4. to build on Curious1997: The medical history appears to be entirely "per the patient", do we have any actual medical records to verify her statements?
  5. d'cm

    How many jobs have you had in your career?

    I've had at least 20 jobs in 25 yrs mostly because I would get fired. I think that should be some kinda record. :-)
  6. Has the thyroid been fully evaluated by imaging and blood work?
  7. d'cm

    New Case Manager

    Doubting yourself is a good thing, it keeps you vigilant. Making a big mistake at this point would be far worse than just not getting everything done. Doubt others also, discharge planning is all about handing off care to some other agency so follow up follow up follow up.
  8. d'cm

    Bombed my interview

    for some reason I thought of this:
  9. d'cm

    How do you deal with workplace discrimination?

    I doubt it was discrimination, just bad managerial skills. You'll find a lot of that in nursing.
  10. d'cm

    Case Study: Joint Pain, Rash, Hair Loss - What's Going On?

    let's do an ELISA test.
  11. d'cm

    ANY Case Managers at United Health?

    United sees nurses purely as an expense. If regulations didn't require us they would not hire them. Evidence of this is that they have been profiting BILLIONS every month but nurses see literal pocket change raises and bonus' .
  12. d'cm

    Hospital CM vs Insurance CM

    I loved hospital cm - it was fast paced, fully focused work and hours flew by, but was terrible at the politics and thus was unsuccessful at it. I do long term care CM for MCO now, work from home, lots of autonomy and no pressure. - but little intrinsic satisfaction. Looking forward to retirement soon.
  13. d'cm

    Hospital CM vs Insurance CM

    I've done both and there are a lot of differences. The core similarity is they both involve discharge planning and utilization review. The big difference is the professional/social/political interaction in the hospital can get very complicated. I found that there are strong financial factors in the hospital setting which interfere with doing the right thing. Not so at all on the payer side.
  14. The most difficult? Knowing which of these duties is most important to someone over you and any given time. 2. Application of process improvement methodologies in evaluating outcomes of care 3. Coordination of communication with physicians, nursing, and staff of ancillary departments 4. Evaluation of care provided against the Length of Stay 5. Collaboration with Admitting to ensure accuracy of patient demographic and insurance information 6. Communication with patients and their families around medical plan of care and discharge plan 7. Assessment and plan for discharge needs and arrangements, including leading multi-disciplinary care conferences and morning 'flash meetings' in conjunction with Nursing. 8. Coordinates/facilitates patient care progression throughout the continuum. a. Works collaboratively and maintains active communication with physicians, nursing, and other members of the multidisciplinary care team to effect timely and appropriate patient management. b. Identifies and resolves delays and obstacles to discharge in a proactive manner. Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. c. Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge. d. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues. e. Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated caseload; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: i) Communication of all elements critical to the plan of care to the patient/family and members of the health care team. ii) Completion and reporting of diagnostic testing. iii) Completion of treatment plan and discharge plan. iv) Modification of plan of care, as necessary, to meet the ongoing needs of the patient v) Communication to third-party payers and other relevant information to the care team vi) Assignment of appropriate levels of care vii) Completion of all required documentation in the IT Case Management screens, and patient records 9. Completes utilization management for assigned patients. a. Applies approved InterQual criteria as a guideline to monitor appropriateness of admissions and continued stays and documents findings based on department standards. b. Identifies at-risk populations using approved screening tool and follows established reporting procedures. c. Monitors length of stay (LOS) and clinical resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. d. Refers cases and issues to physician advisor in compliance with department procedures and follows up as indicated. e. Communicates with financial counselors to facilitate covered day reimbursement certification for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. f. Monitors utilization of resources and reports to Manager. Captures and documents Avoidable Days in Case Management IT system. g. Issues Notices of Non-coverage per hospital policy. h. Provides Part B coverage notification for Observation patients. i. Uphold compliance of regulatory standards for Observation patients including CMS requirement for Code 44. 10. Manages all aspects of discharge planning for assigned patients. a. Meets directly with patient/family to assess needs and develop an individualized plan in collaboration with the physician. b. Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation. c. Ensures/maintains plan consensus from patient/family, physician, and payer. d. Refers appropriate cases for social work intervention based on department criteria. e. Collaborates/communicates with external case managers. f. Initiates and facilitates referrals to the Social Worker as defined in department policy. g. Documents relevant discharge planning information in the System Case Management. IT system according to department standards. h. Facilitates transfers to other facilities. i. Follows ED Case Manager Job Description and Performance measures when assigned to ED. 11. Finance a. Monitors bed availability on assigned unit in conjunction with nurse manager. b. Communicates OBSERVATION LOS to patient and family. Has patient/significant other sign Acknowledgement Form as to status and tentative discharge date and time. c. Initiates calls/communication to managed care companies, on all patients as required. d. Assist in calling for hospital test results in absence of timely reporting to help expedite patient movement. e. Solicits 'Patient Choice' for support services post discharge and confirms in EPIC. f. Monitors appropriateness of resource consumption including orders for CT and MRI. Refers variances to Physician Advisor. g. Knowledgeable about Indigent Medication Programs. Updates and posts list in Physician Lounge areas for physicians and hospitalists. h. Works in coordination with Registration to reduce number of clerical errors in patient status. Makes sure patient insurance correct as well as status. Notifies Registration of changes needed to produce accurate Face Sheet revisions. i. Refer appropriate patients to Financial Counselor. j. Calls insurance company for pre-approval of high cost testing when required. k. Applies Case Management Protocols as applicable. 12. Quality-Actively participates in clinical performance improvement activities by: a. Assisting in the collection and reporting of indicators tracking efficiency of case management processes. b. Use of data to drive decisions and plan/implement performance improvement strategies related for assigned patients, including fiscal, clinical, and patient satisfaction data. c. Collection of delays in service data and data for specific performance and/or outcome indicators as determined by the director. d. Solicits Physicians/Hospitalist in needs related to Case Management activities. e. Attends in-service programs relative to scope of care relative to management of chronic health conditions causing readmissions such as Heart Disease, Cancer, Respiratory Conditions, Arthritis, Hypertension, Diabetes or Depression. f. In the process of chart review screens orders and entries for appropriate signing, pended orders and dating as required by The Joint Commission/CMS. (CPOE)written. g. Practices hospital service initiatives to improve HCAPPS scores. h. Arrange home medications for patients to avoid unnecessary admissions. i. Makes timely referrals to discharge entities as required. Makes referrals to Social Worker as outlined in policy. 13. Service a. Calls and communicates with major payors to discuss pitfalls and problem cases and documents interventions in Case Management IT system. b. Attends unit and committee meetings as required. c. Prioritizes expedition of Observation patients on units. d. Provides relief coverage update on patient caseload and concerns. e. Coordinates 'end of life' discussions with physicians related to patient needs, if indicated. f. Calls and arranges transportation arrangements for patients on discharge. g. Assists in notification of bed availability and readiness on respective unit and communicates to appropriate personnel. h. Notifies patient of hospital discharge time and documents date and time of patient agreement on whiteboard in patient room. i. Confirms with attending physician consultants have signed off case. 14. Growth a. Uses Interqual Guidelines as a coaching tool to aid physicians /hospitalists in appropriate placement of patients. Consults with Physician Advisor as appropriate. 15. Adheres to the Medical Center's Organizational Competencies and the Standards of Behavior.
  15. The actual work of an insurance company case manager is tightly defined by the company. Going in with preconceptions could be counterproductive. The only thing I would suggest is making sure you know how to use Outlook, Word, and Excel.
  16. d'cm

    how to land a case management job?

    Apply at United Healthcare. They are always hiring field case managers.