Case Manager - Registered Nurse

Primary Responsibilities

• Performs utilization review and discharge planning to inpatient admissions to MAH.
• Applies InterQual Inpatient criteria approved by the MACIPA (risk) and MAH (non-risk) Utilization Management Committees to accurately determine appropriateness for inpatient and outpatient care.
• Communicates with attending and house staff when options to inpatient care are identified.
• Utilizes clinical expertise to determine the appropriate level of care for patients. Leads the healthcare team in selecting appropriate, safe, hospital or alternative care options.
• Works with MAH nursing and social work staff to coordinate and facilitate patient discharge.
• Identifies days not meeting acute hospital level of care criteria and reports them to the physician reviewer.
• Works with patients and families to facilitate post hospital care and develop plans to meet short and long-term needs.
• Accurately manages observation status patients by working with physicians to ensure appropriate utilization.
• Is part of the department's Saturday, holiday and beeper rotation as needed.
• Adheres to all insurance, contractual, and regulatory requirements as mandated.
• Abides by MACIPA Case Management standards as per the MACIPA CM guidelines.

Required Qualifications

• Bachelor's degree preferred. Current state license as a Registered Nurse
• Three years of medical/surgical nursing care experience. Two years of case management or utilization management experience required.
• Basic computer and typing skills.
• Effective verbal communication skills and problem solving and conflict resolution skills.
• Demonstrated ability to organize and work independently.