Case Manager

Position Summary

The Case Manager (CM) under the supervision of the Manager, has knowledge and skill in discharge planning, transitions of care, utilization management (UM), medical necessity, and patient status determination. The CM facilitates effective processes based on regulatory and reimbursement requirements of various commercial and governmental payers. The CM assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. They provide cost-effective services while maintaining quality care through collaboration with healthcare providers to coordinate the transition of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement.

Minimum Requirements

• Educational Background: Graduate of an accredited school of nursing, Bachelor’s Degree (other than nursing) with an ADN, or an accredited school of Social Work (MSW)
• Experience: 1-3 years healthcare experience or 1-3 years Case Management experience (Care Coordination, Transitions of Care or Utilization Management)
• Licenses/Registrations/Certifications: Current R.N. licensure in the state of SC or Current Social Work licensure in the state of SC

Preferred Requirements

• Education: BSN, MSW
• Experience: 3-5 years
• Licenses/Registrations/Certifications: RN, LMSW

Core Job Responsibilities

• Complies with established policies and procedures
• Complies with regulatory requirements of utilization review and discharge planning
• Responsible for assessment and reassessment of patients’ physical, social, emotional and financial needs
• Develops a comprehensive patient-centered discharge plan, incorporating the patient’s goals into the plan
• Communicates with the patient/family/caregiver and interdisciplinary patient care team to facilitate patient care, develop a comprehensive discharge plan, and perform utilization review functions
• Negotiates timely decisions to expedite the discharge plan and ensure seamless transitions across the continuum of care
• Documents clearly and concisely all contacts and information related to the patient’s case management process in the medical record
• Performs initial and subsequent utilization reviews using criteria, obtaining certification on admissions and continuing certification by providing clinical information to the payer or review companies designated by the patient’s payer
• Maintains and secures final certification up to and after patient discharge until resolved, monitoring and securing final certification
• Aids in managing incoming faxed communications, assisting with initial denials, peer-to-peer information, status determinations, and appeals processes, communicating necessary information to the physician advisor, CM manager, denials team manager, and/or QIO as required
• Uses communication tools to ensure that information is collected, reviewed, escalated if needed, and disseminated appropriately for all commercial, managed care, and government plans
• Communicates updated insurance information to the centralized referral center if insurance information provided is not accurate
• Timely data entry of information when results are received, including covered, denied, and avoidable days
• Complies with delivery of regulatory notices, such as Important Message, Medicare Outpatient Observation Notice, Detailed Notice of Discharge, and Hospital Issued Notices of Non-Coverage
• Plans effectively to meet patient needs, manage length of stay, and promote efficient utilization of resources
• Provides cost-effective services through resource management and facilitating throughput while maintaining quality care and meeting customer service needs by collaborating with healthcare providers to coordinate care delivery
• Provides patient/family/caregiver with quality data-based information on post-acute providers to facilitate referrals to meet the care transition needs of the patient
• Utilizes a secure electronic platform to communicate with post-acute providers and payers
• Completes required education and ongoing competencies as assigned
• Updates job knowledge by participating in educational opportunities, reading professional publications, maintaining personal networks, and participating in professional organizations
• Performs other duties as assigned