Case Manager Nurse 20016

About the role

This position comprehensively plans for targeted patient populations. Performs resource management, including denial management, utilization management, access to the appropriate level of care, discharge planning, care facilitation, and referral to other levels of care. Works collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes.

Responsibilities

• Manages all aspects of transition/discharge planning for assigned patients in a timely manner.
• Collaborates with all members of the multidisciplinary team to facilitate the transition/discharge process for designated caseload.
• Maintains ongoing communication with the multidisciplinary team and post-acute providers to address any complex family dynamics impacting patient care and transition/discharge planning.
• Initiates and facilitates referrals to post-acute services such as Homecare, Durable Medical Equipment, Hospice Care, Long Term Acute Care Facilities, Acute Rehab Facilities, and Skilled Nursing Facilities.
• Communicates all necessary information regarding transition/discharge plan to the multidisciplinary team, patient and family.
• Aids in the completion of medical power of attorney, health care surrogate, and advanced directives.
• Collaborates for appropriate resource and financial management, including financial assistance coordination/referrals, entitlement program coordination/referrals, or patient benefit coordination.
• Utilizes quality screens in the electronic record to identify potential issues, including but not limited to avoidable delays and readmissions.
• Completes clinical reviews for patients, applying approved utilization criteria to ensure medical necessity of patient’s admissions and continued stays, and documents the findings based on department standards, policy and procedure.
• Screens for appropriate authorization and level of care.
• Fosters the integration of staff and/or students into the healthcare team.
• Facilitates covered day reimbursement certification for assigned patients and discusses payor criteria and issues on a case by case basis with clinical staff (ie. Peer to Peer) and follows up to resolve problems with payors as needed.
• Educates hospital staff and physicians to payer regulations and managed care principals to prevent denials.

Requirements

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• Bachelor’s degree in Nursing (BSN).
• Three (3) years clinical experience.

Qualifications

Minimum Qualifications:

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• Three (3) years clinical experience.

Skills

Knowledge of patient’s current medical insurance coverage and limitations and the precertification requirements for Durable Medical Equipment (DME), post-acute placements, infusions, transfers etc. Knowledge of relevant scientific principles, established standards of care and/or research findings. Knowledge of procedures and techniques involved in administering routine and special treatments to patients. Knowledge of and appropriate application of the nursing process.

Benefits

N/A

Pay

N/A

Schedule

N/A