Case Manager

Case Manager plans, coordinates, develops, evaluates, and monitors the care of assigned group of patients to achieve quality cost effective patient outcomes. Works collaboratively with interdisciplinary teams to identify services required to meet the patient/family needs throughout the continuum of care, while ensuring that appropriate resources are implemented in a timely manner. Meets with all new admissions to identify and discuss a proposed discharge plan and follow the progress of the discharge plan until discharged . Demonstrates knowledge and skills to appropriately communicate and interact with the patients, families, and visitors while being sensitive to their cultural and religious beliefs.Provides case management to improve placement of patients in the most appropriate care setting. Collaborates with physician and registration staff regarding medical necessity and medical review policies to assist in validating appropriateness of admission, services, and continued stay and, if necessary, issue letters of non-coverage. Collaborates with registration staff and physician offices to obtain physician orders for correct level of care assignment. Reviews scheduled Medicare outpatient surgeries for compliance with the APC “Inpatient Only” listing. Collaborates with Physician Advisors or Chief Medical Officer and the attending physician for questioned admissions to ensure an expedited appeal process. Evaluates the use of observation bed services to ensure that patients are either admitted to a higher level of care or discharged in a timely fashion to decrease our potential loss of reimbursement for Medicare observation services and other payors. Performs timely reviews concurrently on assigned patients relative to the prospective payment system for Medicare, Medicaid, private payors, and other hospital utilization management applications. .Serves as the initial contact healthcare providers have with the process of DRG assignment. Functions as the central liaison between the Medicare QIO , review agencies, Business Services, Patient Accounts, and other healthcare professionals affected by concurrent review, DRG assignment, the certification process, and discharge planning. Is involved in utilization review activities as defined by the Utilization Management. Participates on various committees/ task forces as needed. Obtains working diagnoses and procedure codes and a working DRG as needed. Monitors denials and assists with the appeal process as needed. Assembles, analyzes, monitors, and, tracks data t for reporting as designated by the Director.
Performance Expectations:
Demonstrate the aptitude to deal with multiple tasks.
Demonstrate the ability to adapt to change.
Demonstrate the ability to manage daily workload.
Demonstrate the ability to learn and follow various regulatory guidelines.
Education/Skill: Degree from an accredited non-online RN program required. Bachelor of Science in Nursing preferred.
Work Experience: Three or more years of experience in clinical nursing required. Case Management and/or Utilization Management experience preferred.
Certification/Licensure: Three or more years of experience in clinical nursing required. Case Management and/or Utilization Management experience preferred.