RN Case Manager

RN Case ManagerUnder the general supervision of the Case Management Manager acts as a patient advocate/Case Manager to SSH&EC clients. An autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost efficient patient outcomes. Looks for opportunities to reduce cost while assuring the highest quality of care is maintained. Applies review criteria to determine medical necessity for admission and continued stay. Provides clinically-based case management, discharge planning and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care. Works collaboratively with interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. The Case Manager is on-site and available seven (7) days a week as well as holidays and, therefore, is required to work a weekend rotation and also an occasional holiday.Compensation Pay Range: $123,593.60 - $183,726.40Responsibilities include:Reviewing medical records to ensure appropriate utilization and delivery of care.Assisting physicians in determining medical necessity for observation, admission, and continued stays.Identifying cases that fail to meet criteria and referring them to appropriate managers or physician advisors for secondary review.Contacting attending physicians to notify them of decision to issue notice of non-coverage and explaining UR process and insurance coverage requirements.Reinstating insurance coverage when patient condition becomes acute and meets criteria again.Providing clinical data to contracted third-party payers to ensure continued reimbursement.Assisting physicians, nursing, and staff with accurate determination of a patient's observation status.Participating in case finding and pre-admission evaluation screening to assure reimbursement.Assessing patient acute level of care needs and working to implement and coordinate interventions aimed at facilitating a safe and timely discharge plan.Ensuring that patient has received all information related to choice of follow-up care facilities according to patient and family preference and any ACO preferred contracted providers.Interacting, communicating, and intervening with multi-disciplinary healthcare team in a purposeful, goal-directed fashion.Establishing and maintaining effective communication with all referral sources, insurers, vendors, and patient supplier systems.Maintaining an updated knowledge base of provider benefits for care choices, including public, private, and governmental payers and established/preferred ACO relations.Embracing technological solutions to work processes and practices.Job Requirements:Minimum Education - Preferred: Registered Nurse, Bachelors prepared strongly preferredMinimum Work Experience: 3-5 years acute care hospital experience preferred Critical Care or Emergency Department experience highly desirableRequired Licenses / Registrations: RN - Registered NurseRequired Certifications: ACM - Accredited Case Manager or CCM - Certified Case Manager within two years of hire.Required additional Knowledge, and Abilities: Demonstrated skills in the areas of: negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking, time management and ability to multitask in high stress environment. Knowledge of: healthcare financing, community and organizational resources, patient care processes, and data analysis. Knowledge of utilization management as it relates to third party payers Knowledge of post-acute care community resources Experience with Managed Care preferred. Excellent verbal and written communication skills required. Demonstrates flexibility via an ability to adapt to changing priorities and regulations.