RN Case Manager (Part Time) - West Penn Hospital

About the role

A registered nurse proficient in coordinating care and managing coordination of care in accordance with recognized standards of practice for Care Management. Role model utilizing expertise in care management to promote a collaborative professional environment supporting excellence of care and optimal resource utilization.

Responsibilities

• Assumes role in assessment of patient physical, psychosocial, and economic needs for effective transition of care planning to a variety of levels of care.
• Collaborates with the care team to develop and communicate the continuum of care transition plan to appropriate health service providers.
• Documents, verifies, and validates specific data required to monitor and evaluate interventions and outcomes.
• Interviews and collects patient specified data and chart review related to readmission.
• Knowledgeable of and complies with accreditation and regulatory requirements.
• Integrates performance improvement principles and customer service principles into all aspects of job responsibilities.
• Obtains or ensures acquisition of appropriate pre-certification authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party guidelines.
• Obtains or facilitates acquisitions of urgent / emergent authorizations, continued stay authorizations and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements.
• Documents, monitors, intervenes/resolves and reports clinical denials/appeals and retrospective payer audit denials.
• Collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor and third party payers.
• Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory requirements, etc.
• Serves as an educational resource to all AHN staff regarding utilization review practice and governmental commercial payer guidelines.
• Adheres to the policies, procedures, rules, regulations and laws of the hospital and all federal and state regulatory bodies.
• Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
• Assumes responsibility for AHN required continued education and own professional growth.

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 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

Qualifications

• Knowledgeable of and complies with accreditation and regulatory requirements
• Flexibility and adaptability to change
• Strong communication and collaboration skills with ability to tailor style according to target audience (providers, peers, clinical team members, patients, families)
• CPR – American Heart Association
• Act 34 Criminal Background Clearance Certificate
• Act 33 Child Abuse Clearance Certificate
• Act 73 FBI Fingerprinting Criminal Background Clearance Certificate

Skills

• Knowledge of motivational interviewing techniques

Benefits

Incumbents in role as of 12/1/2022 have until 12/31/2025 to obtain

Pay

N/A

Schedule

N/A