Registered Nurse (RN) - Case Manager
About the role
The Utilization Management RN Case Manager (UM-RNCM) at Conemaugh Memorial Medical Center works under the direction of the Case Management Manager to ensure accurate clinical documentation and regulatory compliance. This role involves performing initial clinical reviews of patient records, communicating clinical information to managed care organizations, and collaborating with interdisciplinary teams to facilitate progress in care.
Responsibilities
- Initial clinical reviews of assigned patient records to validate Severity of Illness and Intensity of Service using industry-standard criteria (MCG)
- Escalate cases that do not meet criteria to Physician Advisors and follow up to ensure appropriate utilization and compliance
- Communicate clinical information to managed care organizations to secure authorization for services and reimbursement
- Absorb accurate patient status throughout the hospital stay and collaborate closely with physicians to address and resolve denial determinations
- Collaborate with interdisciplinary team to facilitate progression of care and resource utilization
- Interact with patients and families during the admission process to set expectations for the course of stay and length of stay
- Analyze information from the care team to support inpatient admission
- Assess, identify, and intervene to reduce the risk of barriers that will interfere with the transition of care
- Facilitate optimal care transition to reduce avoidable readmissions
- Follow Case Management policy & procedure for utilizing Physician Advisors
- Interact with attending physicians, physician advisors, and department chairs about quality and utilization issues
- Lead Interdisciplinary Discharge Planning Rounds (IDTs) to determine appropriate concurrent care planning, resource utilization, and post-acute level of care determination
- Identify and document avoidable days and intervene promptly to remove identified barriers
- Follow CMS & regulatory requirements for Case Management processes
- Coordinate concurrent denial/appeal process for assigned cases
- Assume on-call and weekend duties as assigned
- Assist floor(s) with transportation barriers during working hours
Requirements
- Current state RN license
- Associate or Bachelor's degree from an accredited nursing school
- BLS Certification
- 3 years experience in acute care as a Professional Nurse or RN experience with significant acute care hospital Case Management experience
- Previous case management experience preferred
- Case management certification, CP preferred
Qualifications
Qualified candidates must demonstrate strong communication, problem-solving, and organizational skills, as well as the ability to work effectively in a fast-paced, multidisciplinary environment.
Skills
- Strong clinical judgment and decision-making skills
- Excellent interpersonal and communication skills
- Proficiency in utilizing Interqual or the 2MN rule
- Effective collaboration and teamwork abilities
- Ability to manage multiple tasks and priorities
Benefits
Comprehensive benefits package including multiple levels of medical, dental, and vision coverage, financial protection and PTO, higher education and certification tuition assistance, loan assistance, and a 401(k) retirement package with company match.
Pay
Up to $10,000 bonus for eligible candidates
Schedule
M-F 7:30am-4:00pm or 8am-4:30pm + rotating weekends + on call