RN Case Manager Emergency, Allegheny General

Location: Allegheny General Hospital, Case Management Department

Status: Full Time, 80 hours every two weeks (40 hours per week), rotating shifts including day/evening/overnights, weekends, and holidays. Union position.

About the Role

This role oversees, develops, and manages end-to-end claims functions and operational inputs, including receipt of claims, operational and corporate correspondences for multiple customer segments. The position ensures high-performance, efficient, and low-cost production by fully utilizing available support mechanisms. Responsibilities include managing mail services, imaging, Optical Character Recognition (OCR), vendor relations, and communication with operational areas regarding technology-related issues. Additional duties involve utilization review, translation of foreign claims, coordination of benefits (COB), and processing claims with unique arrangements such as Federal Employee Program (FEP) and Medicare Advantage.

Responsibilities

• Coordinates clinical care with the patient, family, physician(s), and other members of the interdisciplinary team.
• Completes and documents admission, concurrent, and discharge reviews of all inpatients and selected outpatients.
• Develops and implements an effective discharge plan incorporating input from the patient, family, physician(s), and interdisciplinary team.
• Identifies, analyzes, collects, and communicates data relative to quality and cost issues for the assigned patient population.
• Expands industry knowledge for professional growth and provides ongoing education to patients, families, physicians, and the interdisciplinary team on topics including appropriateness of care, documentation requirements, severity of illness, insurance benefits, discharge planning, length of stay, and resource utilization.
• Adheres to hospital policies, procedures, rules, regulations, and all federal and state regulatory requirements.

Requirements

• Minimum Bachelor’s Degree in Nursing OR Bachelor’s Degree and Nursing Diploma OR 6 years of relevant experience in lieu of a degree.
• 3 years of experience in a clinical nursing role.
• Current State of PA RN licensure OR current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
• Professional Certification within 5 years of start date.
• Critical thinking and problem-solving skills.
• Flexibility and adaptability to change.
• Strong communication and collaboration skills, with the ability to tailor style to various audiences (providers, peers, clinical team members, patients, families).
• CPR certification (American Heart Association).
• Act 34 Criminal Background Clearance Certificate.
• Act 33 Child Abuse Clearance Certificate.
• Act 73 FBI Fingerprinting Criminal Background Clearance Certificate.