Care Manager Associate

West Tennessee Healthcare•White Deer, TX

About The Position

In collaboration with fellow staff members, and as delegated by the Case Manager (RN) Manager/Supervisor of the Care Management Department, the CMA acts as a consultant to West Tennessee Healthcare inpatient care team and coordinates patient resources throughout the continuum of care resulting in optimal resource management and high customer satisfaction. Care Manager Associates provide education and referral information regarding extended care facilities, placement process, homecare and community resources as appropriate, including levels of care, long term care assessment forms and Medicare / Medicaid rules and regulations regarding placement. ESSENTIAL JOB FUNCTIONS: Proactively facilitates referral, transition, ordering of equipment (e.g. DME), and placement Coordinates with key stakeholders and expedites final transfer with staff, patient, family and facility Maintains contact with appropriate facilities to advocate patient admissions Participates in daily huddles as appropriate to develop and execute the discharge planning and transitions of care Assesses referred patients to determine if appropriate for homecare or placement Updates staff on new facilities and services and maintains a library of reference materials Interprets insurance coverage for homecare of referred patients and obtains approval for services by payer or negotiates method of payment before discharge Obtains commercial payer authorization within the contractual timeframe at time of presentation, every third day or as needed Conducts initial review and continued stay review every third day for Medicare Reviews records for medical necessity and collaborates with physician(s) and members of the care team to validate information May serve as administrative liaison regarding administrative and placement issues Validates authorization for all procedure / bedded patients UR pre-admission. Obtains commercial payer authorization within the contractual timeframe at time of presentation, every third day or as needed. Proactively reduces the risk of denials Manages concurrent cases to resolution. Conducts initial review and continued stay review every third day for Medicare. Reviews records for medical necessity and collaborates with physician(s) and members of the care team to validate information. Confirms that orders reflect level of care, severity of illness and intensity of service utilizing Level of Care Criteria. Establishes and communicates estimated LOS using GMLOS or physician specific measurement. Conducts Level of Care review using electronic system and documents outcomes. Contacts payers as applicable. Refers cases with failed criteria to Physician Advisor and appeals as necessary. Completes stratification tool to identify simple vs complex patient population. Responsible for coordinating and conducting utilization/medical necessity reviews for all payers upon admission & concurrently throughout the inpatient admission in compliance with the WTH Utilization Management Plan. Ongoing collaboration with Case Manager to ensure that patient’s condition meets medical necessity criteria and communicate changes that could affect the discharge plan of care Adheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodies. Incorporates quality improvement findings into daily operations and strategic planning for specific areas. Identifies and participates in educational opportunities that would enhance effectiveness in the role. Performs other duties as assigned or required.

Requirements

Licensed Practical Nurse required
Licensed Practical Nurse Degree or equivalent required
Minimum 2 years’ experience in hospital discharge planning, long term care, and community health - preferred

Nice To Haves

Associates Degree in Nursing (ADN) preferred
Experience in extended care facilities and community agencies preferred

Responsibilities

Proactively facilitates referral, transition, ordering of equipment (e.g. DME), and placement
Coordinates with key stakeholders and expedites final transfer with staff, patient, family and facility
Maintains contact with appropriate facilities to advocate patient admissions
Participates in daily huddles as appropriate to develop and execute the discharge planning and transitions of care
Assesses referred patients to determine if appropriate for homecare or placement
Updates staff on new facilities and services and maintains a library of reference materials
Interprets insurance coverage for homecare of referred patients and obtains approval for services by payer or negotiates method of payment before discharge
Obtains commercial payer authorization within the contractual timeframe at time of presentation, every third day or as needed
Conducts initial review and continued stay review every third day for Medicare
Reviews records for medical necessity and collaborates with physician(s) and members of the care team to validate information
May serve as administrative liaison regarding administrative and placement issues
Validates authorization for all procedure / bedded patients UR pre-admission.
Obtains commercial payer authorization within the contractual timeframe at time of presentation, every third day or as needed.
Proactively reduces the risk of denials
Manages concurrent cases to resolution.
Conducts initial review and continued stay review every third day for Medicare.
Reviews records for medical necessity and collaborates with physician(s) and members of the care team to validate information.
Confirms that orders reflect level of care, severity of illness and intensity of service utilizing Level of Care Criteria.
Establishes and communicates estimated LOS using GMLOS or physician specific measurement.
Conducts Level of Care review using electronic system and documents outcomes.
Contacts payers as applicable.
Refers cases with failed criteria to Physician Advisor and appeals as necessary.
Completes stratification tool to identify simple vs complex patient population.
Responsible for coordinating and conducting utilization/medical necessity reviews for all payers upon admission & concurrently throughout the inpatient admission in compliance with the WTH Utilization Management Plan.
Ongoing collaboration with Case Manager to ensure that patient’s condition meets medical necessity criteria and communicate changes that could affect the discharge plan of care
Adheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodies.
Incorporates quality improvement findings into daily operations and strategic planning for specific areas.
Identifies and participates in educational opportunities that would enhance effectiveness in the role.
Performs other duties as assigned or required.