Case Management-RN

Artesia General Hospital•Artesia, NM

1d•$35 - $55•Onsite

About The Position

The Case Management-RN role at Artesia General Hospital is a Full Time position responsible for directing the daily operations of case management, utilization management, discharge planning, social services, and care transitions. This role involves establishing department goals, workflows, performance expectations, and accountability measures. The position requires providing supervision, coaching, education, and performance evaluation for case management and social services staff, ensuring adequate coverage for various critical functions. Key responsibilities include determining patient medical eligibility, developing and maintaining departmental policies, and promoting effective communication and collaboration among various hospital departments and leadership. The role also assists with departmental budgeting, staffing, productivity, and resource allocation, with a focus on strategies to reduce in-patient length of stay and resource consumption. Additionally, the Case Management-RN oversees the consistent and appropriate application of MCG guidelines, reviews cases for medical necessity and appropriate level of care, and ensures compliance with Medicare regulations, including the Two-Midnight Rule and beneficiary notices. Discharge planning, care coordination, denial prevention and management, and regulatory compliance are also core functions. The position requires a commitment to patient-centered care, regulatory compliance, ethical practice, and responsible resource utilization.

Requirements

Bachelor’s degree in nursing required.
Current, unrestricted Registered Nurse license in the state of New Mexico or eligibility for licensure.
Minimum of five years of clinical nursing experience in an acute-care setting.
Minimum of three years of case management, utilization review, discharge planning, or related experience.
Demonstrated experience using MCG or comparable evidence-based utilization-management criteria.
Knowledge of inpatient, observation, and outpatient status requirements.
Knowledge of CMS regulations, the Medicare Two-Midnight Rule, utilization-review requirements, discharge-planning requirements, and beneficiary notices.
Experience with payer authorization, concurrent review, denials, appeals, and peer-to-peer processes.
Proficiency with electronic health records, utilization-review systems, data analysis, and Microsoft Office applications.
Strong working knowledge of MCG guidelines and utilization-management principles.
Ability to interpret clinical information and communicate medical-necessity concerns clearly.
Ability to build collaborative relationships with physicians and interdisciplinary teams.
Excellent critical-thinking, problem-solving, organizational, and prioritization skills.
Ability to manage multiple complex cases and operational priorities in a small-hospital environment.
Understanding of reimbursement, payer contracts, authorization requirements, and denial risk.
Ability to analyze performance data and translate findings into measurable improvement plans.
Strong verbal, written, and presentation skills.
Ability to manage sensitive situations professionally and maintain patient confidentiality.
Commitment to patient-centered care, regulatory compliance, ethical practice, and responsible resource utilization.
Demonstrates the basic knowledge and skills necessary to identify age-specific patient needs appropriate for this position.
Treats all information and data within the scope of the position with appropriate confidentiality and security.
Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.

Nice To Haves

Minimum of two years of leadership or supervisory experience preferred.

Responsibilities

Directs the daily operations of case management, utilization management, discharge planning, social services, and care transitions.
Establishes department goals, workflows, performance expectations, and accountability measures.
Provides supervision, coaching, education, and performance evaluation for case management and social services staff.
Ensures adequate coverage for utilization review, discharge planning, payer communication, and high-risk patient needs.
Determines Patient medical eligibility, qualifying diagnosis, and determines Medicare/Managed Care eligibility based on skilled services provided.
Develops, reviews, and maintains departmental policies and procedures.
Promotes effective communication and collaboration among case management staff, nursing, physicians, ancillary departments, and hospital leadership.
Assists with departmental budgeting, staffing, productivity, and resource allocation.
Identifies and plans strategies to reduce in-patient length of stay and resource consumption.
Provides patient/ family with information about home health care, skilled nursing facilities, rehabilitation facilities and appropriate providers.
Maintains availability to the patient/family as a resource to facilitate communication among providers and to monitor services rendered.
Oversees the consistent and appropriate application of MCG guidelines for admission, level-of-care, continued-stay, and discharge-readiness reviews.
Ensures MCG criteria are used as a clinical decision-support tool and not as a substitute for physician judgment, applicable regulations, payer requirements, or the patient’s individual clinical circumstances.
Reviews inpatient, observation, and outpatient cases to support appropriate patient-status recommendations.
Ensures timely initial and concurrent reviews, payer notifications, authorizations, and clinical updates.
Escalates cases that do not clearly meet MCG criteria or require additional physician documentation.
Collaborates with attending physicians and hospital leadership regarding inpatient versus observation status.
Facilitates secondary physician review or physician-advisor review when medical necessity or patient status remains unclear.
Supports compliance with the Medicare Two-Midnight Rule and other applicable CMS patient-status requirements.
Ensures required Medicare notices are delivered accurately and timely, including the Medicare Outpatient Observation Notice and other applicable beneficiary notices.
Monitors the use of MCG and identifies educational needs, inconsistent application, and workflow gaps.
Maintains staff competency in the hospital’s current licensed MCG content and documentation requirements.
Reviews admissions and continued stays for medical necessity, intensity of service, severity of illness, and appropriate level of care.
Identifies cases at risk for incorrect status, noncoverage, delayed authorization, or denial.
Communicates medical-necessity concerns promptly to physicians and appropriate hospital leaders.
Facilitates status changes when supported by the patient’s clinical condition, physician order, regulatory requirements, and hospital policy.
Monitors short inpatient stays, extended observation stays, avoidable admissions, and potentially preventable readmissions.
Ensures that patient-status determinations and changes are properly documented and supported in the medical record.
Collaborates with health information management, clinical documentation integrity, patient financial services, and revenue-cycle staff to improve documentation and reimbursement integrity.
Ensures discharge planning begins at admission and is reassessed throughout the hospitalization.
Oversees the completion of initial assessments and the identification of medical, psychosocial, financial, functional, behavioral, and post-acute care needs.
Leads interdisciplinary efforts to develop safe, timely, and patient-centered discharge plans.
Coordinates placement and services involving skilled nursing facilities, rehabilitation facilities, long-term acute-care hospitals, home health, hospice, durable medical equipment, behavioral health, transportation, and community resources.
Ensures patients and families are actively involved in discharge planning and receive understandable information regarding available options.
Addresses barriers that delay discharge, including placement, transportation, medication access, insurance authorization, housing, caregiver availability, and equipment needs.
Facilitates complex case conferences and multidisciplinary care-planning meetings.
Supports safe transitions of care and communication with post-acute providers and primary-care clinicians.
Works to reduce avoidable readmissions and prevent gaps in care following discharge.
Participates in or leads daily interdisciplinary patient progression and discharge-planning rounds.
Reviews each patient’s expected date of discharge, barriers to progression, outstanding tests or consultations, and post-acute needs.
Identifies avoidable delays and escalates unresolved barriers to the appropriate leader or physician.
Collaborates with nursing, medical staff, ancillary departments, and hospital leadership to improve patient flow.
Monitors observation length of stay, inpatient length of stay, avoidable days, discharge order-to-departure time, and delayed discharges.
Develops corrective action plans when performance does not meet organizational goals.
Oversees the identification, tracking, review, and response to clinical and medical-necessity denials.
Ensures payer requests for clinical information are completed accurately and within required time frames.
Coordinates peer-to-peer reviews, reconsiderations, and appeals with physicians, payers, and revenue-cycle staff.
Performs root-cause analysis of denials and develops strategies to prevent recurrence.
Educates physicians and staff regarding documentation patterns that contribute to denials or payment risk.
Tracks denial trends by payer, reason, provider, service line, patient status, and financial impact.
Collaborates with finance and revenue-cycle leadership to improve authorization processes and reduce preventable write-offs.
Maintains compliance with applicable CMS Conditions of Participation, Medicare requirements, state and federal regulations, hospital policies, and accreditation standards.
Supports compliance with patient-choice, discharge-planning, beneficiary-notification, and utilization-review requirements.
Participates in the hospital’s Utilization Review Committee and prepares required utilization data and case reviews.
Maintains confidentiality and complies with HIPAA and other patient-privacy requirements.
Ensures department records, case reviews, notices, and supporting documentation are complete and audit-ready.
Participates in regulatory surveys, payer audits, internal audits, and corrective-action planning.
Maintains current knowledge of changes in reimbursement, utilization management, discharge planning, and payer requirements.
Develops and monitors department performance indicators, including: Inpatient and observation conversion trends, Observation stays exceeding established targets, Initial and concurrent review timeliness, Authorization completion, Inpatient and observation length of stay, Avoidable days and discharge delays, Readmissions, Medical-necessity and authorization denials, Appeal outcomes, Discharges before noon or other established throughput goals, Referral and placement turnaround times, MCG review compliance, Medicare-notice compliance.
Reports performance trends, risks, and corrective actions to hospital leadership and applicable committees.
Uses case reviews and data analysis to identify opportunities for improved quality, efficiency, documentation, and financial performance.
Leads performance-improvement initiatives related to utilization, care transitions, patient flow, and denial prevention.
Develops effective working relationships with attending physicians, emergency department providers, hospitalists, surgeons, and other medical staff members.
Provides education regarding MCG, patient status, medical necessity, documentation, length of stay, and payer requirements.
Communicates physician-specific trends respectfully and objectively.
Escalates unresolved concerns through the established chain of command.
Supports physician-to-physician discussions and peer-to-peer reviews when required.
Serves as a resource to the medical staff regarding utilization-management and discharge-planning requirements.
As assigned.