Advanced Case Manager, RN Preferred

Advanced Case Manager

Milton, LA $57,007 - $72,009 a year

Full Time

We are seeking a dedicated Advanced Case Manager to join our healthcare team in a regional setting within the Southern United States. This role involves comprehensive review and management of patient admissions, ensuring compliance with utilization management criteria, and coordinating care transitions effectively.

Responsibilities

• Review physician orders, emergency documentation, and diagnostic tests to determine admission status using approved criteria.
• Utilize Interqual tools for admission and concurrent reviews.
• Collaborate with admissions and emergency staff to clarify patient status (in-patient vs observation).
• Conduct admission, concurrent, and discharge reviews to obtain insurance authorizations and assign length of stay within designated timeframes.
• Perform admission reviews and discharge screenings within 24 hours, identifying patients needing comprehensive discharge planning.
• Maintain familiarity with patients' medical histories, hospitalization events, anticipated DRG, length of stay, and discharge plans.
• Complete patient assessments within 72 hours, including interviews with patients, families, or caregivers, and review of prior records.
• Evaluate and document patients' needs for post-hospital services, providing appropriate resource lists when applicable.
• Coordinate post-discharge care arrangements such as home health, skilled nursing, rehab, hospice, and durable medical equipment.
• Document interdisciplinary team communications and family involvement thoroughly.
• Incorporate quality and resource measures aligned with patient goals in discharge planning.
• Engage patients and families in continuity of care discussions to ensure agreement on discharge plans.
• Manage communications including voicemail and emails promptly, handling insurance reviews and patient inquiries.
• Participate in quality assurance activities including surveillance and data collection for trend analysis.
• Consult social services as needed based on assessments or physician orders.
• Maintain detailed documentation of authorizations, denials, readmissions, avoidable days, and discharge plans.
• Identify high-risk patients and contribute to readmission reduction efforts by analyzing root causes and coordinating follow-up care.
• Ensure telephone contact with patients within 72 hours post-discharge.
• Attend daily reports and interdisciplinary team meetings to discuss patient status and discharge planning challenges.
• Keep physicians informed of patient progress and collaborate on care goals.
• Appeal insurance denials within required timeframes.
• Coordinate discharge and transfer logistics, ensuring all clinical information and documentation are complete and accurate.
• Stay updated on relevant laws, regulations, and guidelines such as those from Centers for Medicare and Medicaid Services.
• Perform additional duties as assigned to support organizational mission and values.

Education & Experience

Preferred candidates will hold licensure as a Registered Nurse or Licensed Practical Nurse and have experience in case management or related clinical roles.

Licenses & Certifications

• Advanced Cardiac Life Support (ACLS) preferred
• Basic Life Support (BLS) required
• Licensed Practical Nurse (LPN) or Registered Nurse (RN) licensure preferred