Resource Case Manager / Utilization Review Specialist - Hybrid

***ROLE IS APPROXIMAELTY 50% REMOTE WITH 50% STATEWIDE TRAVEL COVERING LEAVES, PTO, ETC.***

At Kindred It Starts With Me. 

Our commitment is to deliver excellence and an empathetic human experience to every patient, every family member, every employee, every time. We do this through our Core Values which help in guiding our work every day.

Job Summary: The Resource Case Manager serves as a subject matter expert in case management, offering operational expertise within the case management departments across multiple Kindred hospitals. Coordinates and facilitates the care of the patient population through effective collaboration and communication with the Interdisciplinary Care Transitions (ICT) members. Serves as a subject matter expert, mentor and preceptor to staff, performing staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery. Follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with external review agencies. Provides ongoing support and expertise through comprehensive assessment, care planning, plan implementation and overall evaluation of individual patient needs. Enhances the quality of patient management and satisfaction to promote continuity of care and cost effectiveness through the integration of functions of case management, Utilization Review and management, and discharge planning. Partners with external customers, referral sources, and payors to ensure the facilitation and coordination of the discharge planning process and serves as the patient and family advocate.

Essential Functions:

Care Coordination

• Serves as a subject matter expert in the daily coordination of patient care to facilitate development, monitoring, and refinement of treatment plan.
• Works with the Director of Case Management to ensure areas of responsibility are operating in compliance with CMS, State and JCAHO regulations and standards and with Kindred policies, including documentation and record requirements.  Actively participates in surveys and audits.
• Coordinates clinical and/or psychosocial activities with the Interdisciplinary Team and Physicians.
• Monitors all areas of patients' stay for effective care coordination and efficient care facilitation.
• Remains current from a knowledge base perspective regarding reimbursement modalities, community resources, case management, psychosocial and legal issues that affect patients and providers of care.
• Appropriately refers high risk patients who would benefit from additional support. 
• Serves as a patient advocate.  Enhances a collaborative relationship to maximize the patient's and family's ability to make informed decisions.
• Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate care to the patient population served.
• Participates in interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, and to provide education to patients and families on identified post hospital needs. Collaborates with clinical staff in the development and execution of the plan of care, and achievement of goals.
• Coordinates with interdisciplinary care team, physicians, patients, families, post-acute providers, payors, and others in the planning of the patients' care throughout the care continuum.

Discharge Planning

• Conducts comprehensive, ongoing assessment of patients to provide timely and safe discharge planning.
• Provide comprehensive discharge planning for each patient. Utilizes critical thinking to develop and execute effective discharge planning.
• Coordinates and communicates with patient/family efficiently and effectively.

Utilization Management

• Conducts medical necessity review for appropriate utilization of services from admission through discharge.
• Promotes effective and efficient utilization of clinical resources.
• Conducts timely and accurate clinical reviews, care collaboration and coordination of continued stay authorization with payor.

Education:

Graduate of an accredited program required:

• RN, BSN preferred

OR

• Master of Social Work with licensure as required by state regulations;

OR             

• Bachelor of Social Work with licensure as required by state regulations

Licenses/Certification:

• Healthcare professional licensure required as Registered Nurse or Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) if required by state regulations.
• Certification in Case Management preferred.

Experience:

• Two years of experience in healthcare setting preferred, preferably acute or LTACH.
• Prefer prior experience in case management, Utilization Review, or discharge planning.

Knowledge/Skills/Abilities/Expectations:

• Knowledge of government and non-government payor practices, regulations, standards and reimbursement.
• Knowledge of Medicare benefits and insurance processes and contracts.
• Knowledge of accreditation standards and compliance requirements.