RN

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PRN position Case Management Department

General Description of the Job Class

• Perform a variety of specialized, complex activities in the coordination of the care needed for patient discharges and transitions of care. Strong emphasis on proactive problem resolution and departmental communications.
• Independently perform activities necessary to organize, maintain, and use electronic patient health records. Positions at this level have high customer service, strong analytic and problem solving skills, require interpretation and explanation of policy and external requirements related to, privacy, release of information, positive patient identity, and other department and organization-wide functions.
• Regular interaction required with case management staff, physician advisors, post-acute care providers, community based organizations, insurance companies, and governmental agencies.
• Detailed working knowledge and ability to apply HIPAA rules, North Carolina General Statutes, and other State and Federal laws regarding patient privacy. Detailed working knowledge and ability to apply State and Federal laws regarding discharge planning, Joint Commission requirements, and CMS guidelines and rules.

Duties and Responsibilities of this Level

• Partners with Case Management team in arranging for discharge needs of patients including but not limited to durable medical equipment, home health, facility placement, dialysis, outpatient appointments, back transfers to outside hospitals, transportation, and home infusion.
• Performs a variety of specialized, complex activities in the coordination of post-acute care services. Reviews discharge planning forms for completeness, timing, and conformity to policy and guidelines. Delivers the Important Message from Medicare according to CMS guidelines to all indicated patients based on case manager's noted expected discharge date.
• Participates in daily Case Management touchpoints with Case Managers, Social Workers, and Utilization Managers. Discusses referred cases, including, patient status, barriers to discharge, payer communication, expected discharge date, transition planning priorities, escalations and support needed.
• Reviews insurance coverage updates on all appropriate patients, as assigned. Regularly evaluates work list and re-prioritizes items for the day. Reviews requests for care coordination to identify dates of service, entity, provider and specific clinical documents needed to complete the requested referrals. Works extensively in the electronic health record to locate specific clinical documents for the purpose of fulfilling a request. Escalates more complex inquiries and barriers to the appropriate resource.
• Stays in close contact with the requester to alert Case Management Staff of barriers to completion of needed task, provide status updates and ultimately share details of case completion. Enters appropriate documentation of all discharge planning activities and communications according to department standard and closely monitors pending tasks and priority level of each task.
• Maintains strong working relationships with both internal Duke staff as well as external agency staff such as post-acute liaisons, admissions coordinators, medical providers and staff in community-based organizations to ensure timely, appropriate and safe transitions of care.
• Obtains all authorizations for SNF care, both by utilizing the NaviHealth portal for the payers who utilize that system as well as any other processes used by all other managed care and health plans. They will also use a similar system as NaviHealth utilized by the State to approve all post-acute care (including Home Health) for Medicaid beneficiaries covered by these commercial plans.
• Schedules peer-to-peer reviews for Physician Advisors (PAs) and communicate electronically to the PAs the dates/times and contact names/numbers of the payer's Medical Director with whom they will be speaking. Discusses rationale for initial denial of services with the PAs to assist in their preparation for the peer to peer discussion. Meticulous record keeping of this process will be expected as data will be needed to assess volume for future expansion.
• Develops, administers activities, monitors and evaluates program effectiveness, and investigates trends. Advises supervisor as to the status of current activities and additional or expanded program requirements. Provides input into appropriate program recommendations or conclusions. Assists in developing and defining short and long term departmental specific goals and objectives. Implements decided upon program adjustments. Coordinates projects and audits to improve processes related to Case Management efficiency of care coordination and discharge planning.
• Requires the ability to interpret and explain policy and external requirements related to, discharge planning, release of information, positive patient identity, and other department and organization-wide functions. Completes regular interaction, as indicated, with governmental agencies, providers of health care, insurance companies and auditing agencies. Possesses a detailed working knowledge and ability to apply HIPPA rules and other State and Federal laws regarding patient privacy. Possesses working knowledge of Joint Commission requirements and CMS guidelines and rules.
• Develops, coordinates and advises staff regarding relevant policies and guidelines. Educates and trains employees in proper methods and procedures to ensure efficient and accurate completion of work. Develops and provides job-specific training to new and existing employees within department.

Required Qualifications at this Level

Education

Associate's degree in business, healthcare administration, social work or a related healthcare

Bachelor's degree in business, healthcare administration, social work or a related health field highly preferred

Experience

2 years of related experience required

A Bachelors degree in related field can subsitute for the experience requirement

Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.