Case Manager-RN

Responsible for the quality and resource management of all patients that are admitted to the facility from the point of their admission and across the continuum of the health care management. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and ensure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive concurrent review of the medical record for the medical necessity, intensity of service and severity of illness.

Demonstrates knowledge of all types of payer systems, including Medicare and Medicaid

Integrates with all care centers in hospital, addressing a variety of age-specific concerns. (Neonates to Geriatrics)

Recognizes and addresses the psychosocial, cultural, and spiritual needs of patients and significant others, as evidenced by the discharge plan

Demonstrates knowledge of and participation in Performance Improvement activities

Performs concurrent and retrospective review in a timely manner utilizing criteria approved by the Utilization Review Committee. Determines priorities for the order in which patients need to be reviewed

Applies appropriate clinical judgment in the concurrent review process to ensure that information in the medical records meet the criteria for intensity of care level of service for continued hospital stay and/or discharge

Documents all deviations from criteria for continued length of stay and promptly discusses these with the attending physician and/or Medical Director

Communicates daily, as needed, with the Medical Director, or his designee, regarding concurrent reviews and/or difficulties with resource utilization

  • Participates actively in discharge planning; coordinating appropriate discharge plan based upon the identified needs of the patient and the availability of resources
  • Functions as the primary liaison with the Medicaid field representative and other Medical providers within the hospital
  • Communicates, as requested by insurance carrier, needed information regarding intensity of care and level of service for admissions and observations. Abides with HIPAA regulations
  • Integrates with various departments in order to enhance patient outcomes
  • Interacts with insurance companies and 3rd party payers to obtain authorizations for initial and continued hospital care
  • Assumes responsibility for the prevention of Medicare, Medicaid, HMO and / or other insurance denials.
  • Performs retro reviews, when requested, on patients who have been discharged
  • Assists in appeal process on any insurance denial and coordinates Physician to Physician reviews
  • Participates proactively in the goals and objectives of the Case Management Department in reducing medically aberrant LOS, and establishes personal goals to achieve desirable outcomes organizationally
  • Performs other duties as assigned or required
  • Participates actively and positively affects the outcome of customer service activities
  • Demonstrates and maintains thorough knowledge of Federal, State, Local Laws and CMS/JCAH accreditation standards
  • Understands and actively participates in the hospital-wide Quality Improvement Process using the Plan/Do/Check/Act (PDCA) process
  • Is able to define performance improvement and verbalize at least one departmental or hospital-wide improvement initiative that has occurred in the last 12 months
  • Follows standard precautions and transmission-based precautions as demonstrated by consistent use of appropriate personal protective equipment
  • Uses proper body technique at all times. Seeks assistance when necessary to move heavy objects or to transport/transfer a patient
  • Must have a current and valid license as a Registered Nurse issued by the state of Ohio
  • Experience in using Interqual criteria and Milliman desired
  • Three years acute care nursing experience, critical care/ER experience preferred, previous case management experience preferred, certification in case management preferred
  • Highly motivated, assertive, computer skills necessary, knowledgeable in community resources and alternate care facilities, demonstrates exceptional written and verbal communication skills
  • BLS upon hire and maintain current