Case Manager-Inpatient-Acute Observation

About the role

Applies Case Management principals in coordinating patient care across the continuum using assessment, care planning, implementation, coordination, monitoring and evaluation for cost effective and quality outcomes in a primarily inpatient setting, including complex discharge planning. Performs Utilization Management clinical review to ensure that services rendered to members meet clinical criteria and are delivered in the appropriate setting. Utilizes clinical skills and knowledge to coordinate, document and communicate all aspects of the utilization/benefit management program. Performs care review both prospectively and retrospectively. Prospective review includes pre-service and concurrent services and procedures. Validates and interprets medical documentation using evidence-based criteria sets. Consults with PHP medical directors and refers for medical director decision on cases not meeting clinical criteria. Identifies members with complex conditions requiring one on one case management and/or disease management services and refers appropriately to the Presbyterian Integrated Care Management program. Located at 9521 San Mateo NE, Albuquerque, NM 87113-2237.

Responsibilities

• Receives, reviews, verifies and processes requests for approval of pre-service and concurrent services including verification of eligibility and availability of benefits.
• Identifies and advocates for members in caseload, referring to appropriate inpatient, outpatient and community resources including care coordination.
• Conducts an in-depth assessment which includes, psychosocial, physical, medical, environmental and financial parameters.
• Collaborates with Healthcare team to proactively develop, implement and document treatment and discharge plan with appropriate resources to address social, physical, mental, emotional, spiritual and supportive needs.
• Collaboratively formulates, implements, coordinates, monitors, and evaluates strategies with the healthcare team to address care management issues for specific patients and disease processes.
• Applies utilization review criteria to assess and document the appropriateness of admission, continued stay, level of care, and readiness for discharge; refers cases that do not meet criteria to designated Physician Advisor.
• Promotes the appropriate use of clinical and financial resources in order to improve quality of care and patient/member satisfaction.
• Advises manager/supervisor of possible trends in inappropriate utilization (under and/or over), and other quality of care issues.
• Communicates effectively with providers, PHP medical directors, Members, PHP departments as evaluated by supervisory audits.