Care Manager I

Responsibilities

• Manages an assigned caseload of patients from preadmission to discharge.
• Assumes responsibility for admission appropriateness (medical necessity), (outpatient, observation, inpatient admission), continued stay, and medical record monitoring.
• Captures and coordinates communication with third party payers, external review agencies and the Utilization Committee.
• Identify managed care issues and address promptly as related to denials management.
• Coordinates and collaborates with physicians, provider, multidisciplinary team and other health care professionals concerning patient’s goals, plan of care and progress.
• Revise and adjust on a daily basis the plan of care to accommodate the needs of the individual patient based on continuing assessment of patient condition.
• Serves as a leader of discharge planning multidisciplinary team meetings, ensures documentation of meetings.
• Advocate for the patient/family and is knowledgeable of and act in accordance with legal principles of consent, healthcare proxies (power of attorney for healthcare) and advance medical directives.
• Stays abreast of developments in the case management field and seeks ongoing education to enhance practice skills.
• Willing to seek certification in case management field if made available through ARH.
• Stays abreast of regulatory agency guidelines as pertains to area of practice.
• Initiates and monitors clinical care guidelines and analyzes positive and negative variances.
• Ensures continuity of care through formulation of discharge plan on admission and follow though until patient is discharged.
• Ensures appropriate use of resources.
• Makes sure that length of stay is appropriate based on medical necessity.
• Works with medical staff, hospital staff, and others to overcome barriers to discharge.
• Makes sure that in-house denials for extended lengths of stay are monitored.
• Participates in the denials management process to help ensure establishment of and adherence to processes that will minimize denials by third-party payers.
• Participates as a member of the Utilization Committee.
• Aids in the collection of data to trend and analyze outcomes for identification of improvement opportunities.
• Assists in the collection of data, specific to outcomes data.
• Assesses the appropriateness of the level of care; diagnostic testing and clinical procedures; quality and clinical risk issues; and documentation of medical record completeness.

Qualifications

• Associate's Degree in Nursing (RN licensed in state of employment).
• Possession of a Bachelor's Degree in Nursing preferred but not required; must be obtained within 5 years.
• Preferred 4-6 years of nursing experience may be considered with demonstration of skills required for the position.
• Prior experience in case management field preferred.
• Prior experience in utilization review preferred.
• Prior experience in managed care preferred.
• Advanced knowledge of problem solving and decision making skills.
• Strong multi-tasking abilities with the ability to handle competing deadlines; flexible and adaptable.
• Ability to deal tactfully with customers and community.
• Advanced communication skills used to lead a team.
• Advanced execution and delivery (planning, delivering, and supporting) skills.
• Ability to consider the relative costs and benefits of potential actions to choose the most appropriate one.
• Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients.
• Mastery knowledge of phases of care transitions and resources available for patients.
• Mastery of digital literacy skills.
• Ability to handle sensitive information ethically and responsibly.