Clinical Case Manager

This position works closely with the interdisciplinary team to facilitate and maintain compassionate, safe and efficient quality care and achieve desired treatment outcomes. This position works closely with the team to ensure effective discharge planning and continuity of care; and communicates clinical information to payers to ensure reimbursement. Job Duties and Responsibilities Collaborates with the physician and team to facilitate care, monitor the patient’s progress, intervening as needed to ensure high quality, efficient, and cost-effective services to the patient that are timely. Educates staff and serves as a resource for meeting needs of the patient and facility. Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care and program compliance. Identifies when services no longer meet criteria, initiates discussion with physicians, coordinates with the external case manager to facilitate discharge planning, seeks assistance from physician advisor when needed, and informs management of possible need for issuing Medicare Hospital Initiated Notice of Non-coverage. Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay. Reviews level of care denials to identify trends and collaborates with team to recommend opportunities for process improvement. Plans for routine/difficult discharge and anticipates/prevents and manages emergent situations. Specific focus is given to discharge plan and elimination of barriers. Performs post-discharge review by analyzing the medical record to ensure that compliance with quality indicators is met. Communicates reports to appropriate leader regarding regulatory concerns. Monitors length of stay (LOS) on an ongoing basis. Proactively takes action to expedite care/facilitate discharge. Manages all patients in observation status, daily, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital. Secures reimbursement for hospital services by communicating medical information required by all external review entities, managed care contracts, insurers, fiscal intermediaries, and state/federal agencies. Responds to requests for information, monitors covered days, initiates review to assure that all days are covered and reimbursable. Supports and follows the mission, vision, values and policies of the hospital and communicates with the appropriate leadership and staff. Qualifications (Education, Experience and Certifications) Education RN graduate from an accredited nursing program. Master’s Degree preferred. Certification, Licensure Current license as a registered nurse in the state of Texas; current American Heart Association BLS certification. Experience, Training, Knowledge Three (3) years hospital clinical experience; two (2) years case manager experience. Knowledge, Skills and Abilities Strong assessment, organizational and problem solving skills Knowledge of Medicare, Medicaid and managed care requirements. Comprehensive knowledge of community resources, healthcare financial and payer requirements and eligibility requirements for county, state and federal programs. #J-18808-Ljbffr