Case Manager (Full-Time)

Job Title

Qualifications:

Experience:

Previous C.M. Experience

Substantial clinical experience

Education:

Bachelor's degree (required)

Masters (preferred)

Licensing:

Foreign Medical Graduate or Registered Nurse (preferred)

CCM (Certified Case Manager) (preferred)

ACM (Accredited Case Manager) (preferred)

Bilingual (English/Spanish) (preferred)

Responsibilities:

Performs and documents patient assessment within 24 hours of admission

Checks prior authorizations initiative by admitting

Knowledge navigating and using payer portals

Performs concurrent reviews:

Contacting all HMO's on a daily basis and provides clinical information to obtain insurance authorization for the patient's admission and continued stay

Indicates the appropriate level of care and utilization of services needed

Establishes criteria for medically necessary services:

Knowledgeable of Milliman Care and Interqual Guidelines

Develops a plan of care for patients from admission to discharge.

Promotes the most efficient and cost-effective use of services

Curtails the performance of inappropriate and/or duplicate services

Encourages standardization of medical practice patterns

Enhances the quality of healthcare

Performs concurrent reviews for patients to ensure that extended stays are medically justified and are documented in patient's medical records.

Calculates and manages the lengths of stay and continued-stay days for patients.

Evaluating the patient's condition and readiness for discharge planning

Develops discharge plans

Communicate and assist the physicians in the planning and coordination of patients discharge planning

Management of transfer procedures

Management of the guardianship process

Able to discuss and educate patient/family regarding discharge planning and resources available after discharge. Clearly specifies all the information discussed with the patient and/or family regarding the patient's discharge plan.

Participates in PI programs through the identification of opportunities for improvement, data collection, evaluation of findings, improving the process, applying knowledge and incorporates into practice

Scheduling Peer-to-Peer reviews with payors

Proactively identifying and resolving issues that could lead to denials

Skills:

Familiarity with Medhost electronic medical records

Extensive medical knowledge

Self-driven (work and education)

Keeps knowledge up to date by reading literature and participating in outside continued education meetings, training, and conferences

Working knowledge of regulatory agencies

Excellent human relations and communication skills (verbal and written) to maintain good rapport and effective working relationships with medical staff, nursing staff, and other ancillary department staff throughout the hospital

Excellent organizational skills and attention to detail

Ability to convey care plan to physicians and the medical team

Proficient with Microsoft Office Suite or related software.

Integrity