Description of CM Outcomes Management Duties
Outcomes Management provides clinical expertise to acute or chronically ill patients. The responsibilities include direct patient care, support of systems, education, research, and professional leadership. Understanding services to meet an individual’s health needs using communication and available resources to promote quality, cost-effective outcomes throughout the continuum is essential.
Outcomes manager functions:
• Manages a complex patient caseload/coordinates interdisciplinary team.
• Performs patient assessment and management/revises plan of care with interdisciplinary team.
• Enhances the continuity of care by providing a smooth transition to the next level of care.
• Acts as resource, patient advocate, and communicator.
• Develops, implements, and evaluates clinical pathways.
• Tracks clinical/financial/functional outcomes data.
• Addresses clinical process improvement, performance improvement, and variance tracking.
• Collects, analyzes, and evaluates data to identify process improvement opportunities.
• Participates in clinical research projects.
Case Management is a collaborative process. Responsibilities include discharge planning, clinical understanding, utilization review, and process improvement. Coordinating clinical and financial outcomes of an assigned patient population in a timely, cost-efficient and effective manner during the acute phase of a patient’s stay is essential.
Case manager functions:
• Performs unit-based collection and assessment of patient medical information on a concurrent basis for 100% of admissions for payer and interdisciplinary team.
• Identifies appropriateness of patient admissions and continuing stay.
• Communicates appropriate information to third-party payers.
• Identifies referrals to social services and coordinates activities related to discharge planning.
• Acts as resource for completing retrospective reviews as requested by centralized department.
• Acts as resource for processing third-party payer denials and appeals as requested by centralized department.
• Facilitates the Clinical Documentation Management Program.
• Educates doctors or office staff regarding insurance contract changes, direct admissions to SNF, admission criteria, admission reviews.
Source: Grant/Riverside Methodist Hospitals, Columbus, OH.
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