Case Coordinator / Nurse-Case Management

Role Overview

Case Coordinator / Nurse-Case Management at Sheikh Shakhbout Medical City (SSMC). This position coordinates with the multidisciplinary team and accredited healthcare providers under the guidance and supervision of the Senior Case Coordinator to ensure quality patient care and timely progression of the patient's episode of care.

Role Purpose

To coordinate appropriate healthcare providers and services, manage utilization and medical necessity, facilitate resource allocation, and ensure efficient discharge planning while maintaining patient advocacy and cost-effective care delivery.

Key Responsibilities

Patient Care Coordination

• Maintain active communication with physicians, nursing, and multidisciplinary team members for appropriate patient care management.
• Consult from appropriate disciplines and departments as required to expedite care and facilitate discharge.
• Assess and intervene to address psychosocial needs including patient, family, and community concerns, collaborating with social workers as appropriate.
• Act as a patient advocate by facilitating education based on identified learning needs of the patient and those providing care.

Utilization Management & Medical Necessity

• Manage evidence-based Medical Necessary screening criteria in support of admission and continued stay reviews.
• Determine correct level of care placement through utilization management.
• Communicate with payers as necessary regarding medical necessity and insurance criteria.
• Ensure patient care is rendered to the maximum stipulation based on the patient's benefits under the insurance contract without exceeding the provider's cost provision.
• Support physicians in relation to clinical documentation impacting Medical Necessity, Case Mix Index, and Severity of Illness.

Resource Planning & Financial Liaison

• Facilitate resource utilization to ensure available funding meets clinical needs.
• Plan utilization of resources and monitor that funding aligns with clinical requirements.
• Act as a liaison between clinician and revenue department.
• Ensure proactive discharge planning.

Clinical Pathway & Discharge Management

• Identify and resolve variances to clinical pathways and obstacles to discharge.
• Facilitate along the Continuum of Care, monitoring against Clinical Pathway and facilitating transition plans.
• Monitor patient progress and intervene as necessary to ensure the plan of care is patient-focused, quality efficient, and cost-effective.
• Monitor length of stay and resource use on an ongoing basis and discuss trends with Senior Case Manager.

Reporting & Documentation

• Provide accurate medical documentation and health insurance documentation.
• Assist in the collection and reporting of indicators including length of stay, excess days, resource utilization, and readmission rates.
• Participate in regular communication and feedback with Senior Case Coordinator.
• Monitor and intervene as necessary to achieve desired goals and outcomes for both the patient and the hospital.

Qualifications & Experience

Education

• Bachelor's Degree in Nursing.
• Degree in Nursing with minimum two years course duration and Registration as a Registered Nurse from Canada, USA, UK, Ireland, South Africa, New Zealand, or Australia.
• Valid and current national license.
• BLS certification.

Certifications

• Case Management Certification.

Experience

• Six years' experience in SSMC as staff nurse, OR
• Six years of experience of which not less than two years in Case Management in a similar healthcare facility.
• Experience in large healthcare facility is desired.