Peri-Operative Case Manager

Job Summary

The peri-operative nurse case manager combines clinical documentation optimization, preoperative risk stratification, and case management expertise. The primary purpose of this role is to have a comprehensive, systematic approach to optimize workflows, pre-op risk assessment and documentation before, during, and after surgery, with an emphasis on surgical medical necessity, status appropriateness, and prior authorization. The role is a specialized position that combines oversight of the medical record with coordination of patient care focusing on regulatory compliance, improving patient outcomes, and managing healthcare resources efficiently. The role simultaneously manages patient cases, ensuring complete and accurate medical record documentation for coding and reimbursement and identifying high-risk surgical populations with chronic conditions or advanced age, while collaborating with the healthcare team to improve quality of care and documentation. The peri-operative case manager, working under the direction of case management leadership, in conjunction with office managers, directors, clinical documentation specialists, coders and lead physicians, will have utilization review and compliance expertise to identify and facilitate modifications to quality and completeness of medical record documentation and allow for early identification of clinical, functional, and social risk factors that may influence admission status, length of stay, and discharge needs for surgical patients. The perioperative case manager will be responsible for aligning workflows, assisting with pre-operative risk assessment, and documentation to ensure financial, compliance, and operational optimization.

Supervises the Following Positions

Positions: N/A

Physical Requirements

• The ability to perform the duties and responsibility of the position, with or without reasonable accommodations for disabilities.
• The ability to consistently lift, push or pull loads of up to fifty (50) pounds. (Unless nursing 50)
• Sufficient strength, mobility and stamina to make frequent location and position changes, assist with patient care, and perform other physical activities of average difficulty.
• Candidates whose disabilities make them unable to meet the requirements will still be considered fully qualified if they can perform the essential functions of the job with reasonable accommodations.
• May be exposed to infectious or contagious disease.
• May have to handle emergency situations.
• May be subject to irregular hours.
• May be required to wear protective equipment such as eye protection, face protection, masks, sterile/nonsterile gloves, isolation gowns.
• May be exposed to toxic/caustic/chemicals/detergents.
• Physical activities include continuous sitting, and occasional walking, standing, bending, squatting, climbing, kneeling and twisting.
• Activity Conditions (Occasionally, Frequently, Continuously):
  • Sitting- Continuously
  • Walking- Frequently
  • Standing- Frequently
  • Bending-Frequently
  • Squatting- Frequently
  • Climbing-Occasionally
  • Kneeling-Occasionally
  • Twisting-Occasionally
  
  

Visual and Hearing Requirements

• Must be able to see with corrective eye wear.
• Must be able to hear clearly with assistance

Working Conditions

Primarily Works in a well-lighted and air-conditioned environment with period of heavy workload and stress. Works in various conditions.

Performance: Essential Functions

Decision Making: Ability to make decisions and takes appropriate action based on the information they have. Recognizes own limitations and consults with the supervisor, manager, or team member when appropriate.

Time Management: Works efficiently and manages duties to ensure that tasks are completed with accuracy and within the scheduled shift or reasonable amount of time.

Quality & Quantity: Demonstrates accurate, knowledge and skill to carry out job duties. Follows departmental work policies and procedures. Speed and consistency of output, and time utilization of job duties.

Computer Knowledge & Electronic Equipment Use: Demonstrates ability to consistently utilize electronic equipment and online computer programs to perform job duties, including electronic documentation, and order entry.

Resource Utilization: Consistently utilizes and maintains supplies and equipment to minimize lost charges and unnecessary equipment repair-replacement.

Confidentiality: Adheres to established policies on privacy and security requirements for compliance with the Health Insurance Portability and Accountability Act (HIPAA), as applicable by Shannon Policy.

Performance: Position Specific Essential Functions

• Onsite clinical collaboration working directly with the healthcare team to attend meetings, provide education, and discuss specific cases.
• Collecting patient information related to diagnosis and care by conducting chart reviews.
• Assessing documentation validity via utilization review, analytic software, and critical thinking skills to: modify risk by developing recommendations for risk reduction such as patient safety indicators; improve the clinical depiction of the patient leading to better quality outcomes in surgical settings; contribute to hospital efficiency, cost savings, and appropriate use of resources; provide data for performance metrics and quality initiatives.
• Identifying and communicating documentation or risk assessment opportunity with providers (for needed documentation support, ambiguity, or conflict).
• Meeting productivity requirements established in department standards.
• Collaborating with physicians, nurses, and other clinical staff to clarify documentation, address gaps, identify opportunities for improvement in the documentation process, and provide education on best practices for accurate and compliant record keeping.
• Upholding the integrity of the hospital medical record by complying with organizational, legal, ethical, and regulatory requirements.
• Manage patient cases from admission through discharge by ensuring that necessary documentation supports the care plan and subsequent billing.
• Providing superior customer service to customers and coworkers with professional conduct and respectful behavior.
• Strong interpersonal skills that allow for effective communication with different levels of hospital personnel
• Solid verbal and written communication skills required.
• Organization, prioritization, critical thinking, and attention to detail are needed.
• Basic computer and office equipment knowledge; Electronic Medical Record training provided.
• Prior knowledge of medical and pharmacology terminology required.
• Performs other duties as assigned.

Qualifications

Education

• Required
  • High School Diploma
  • Associate's degree in nursing
• Preferred
  • Bachelor's degree in nursing

Experience:

• Required
  • Five years of experience in acute care/hospital setting
• Preferred
  • One year of experience in clinical documentation improvement, utilization review, and/or acute care case management

Certification/Licensure:

• Required
  • Registered Nurse (RN) with Authorization to Practice in the State in Texas
• Preferred
  • CCM/ACM or relevant clinical documentation certification