CASE MANAGER BEHAVIORAL HEALTH

Independence Health System•Latrobe, PA

11h•Hybrid

About The Position

The Case Manager Behavioral Health role is responsible for completing initial utilization reviews for medical necessity for an assigned patient population, initiating assessments within 24 hours of admission or the next business day, and applying Interqual criteria for severity of illness/intensity of service indicators/medical necessity criteria. The role involves recognizing and progressing the plan of care when an alternative level of care is appropriate, conducting continued stay reviews by monitoring patient's response to treatment and resource utilization, and collaborating with the Attending Physician and healthcare team to facilitate the progression of the plan of care. Additionally, the position requires completing initial and continued stay reviews in a timely manner, in accordance with various payor contracts and guidelines, and being cognizant of payor requirements for all patients in the assigned caseload. Accurate and timely documentation in recognized databases to support Clinical Resource Management components for each patient is also a key responsibility. The role also manages denial processes, including initiating contact with the Attending Physician on cases not meeting SI/IS indicators, educating the healthcare team on Interqual criteria, and encouraging physician participation in the appeal process. Notification to the Manager of all real or potential adverse determination cases and identification/facilitation of transition to an alternate level of care are also part of denial management. For discharge planning, the Case Manager assesses, plans, and facilitates appropriate discharge plans in collaboration with the patient/family, physician, and healthcare team, coordinating alternate levels of care based on patient needs and resource availability. The role also involves creatively resolving complicated disposition issues, utilizing community resources, and providing information and limited counseling for appropriate referrals. Maintaining patient rights by adhering to HIPPA, Freedom of Choice, Rights of Reconsideration, and other regulatory agency requirements is essential. The position also involves active positive communication/collaboration with internal and external agencies, daily interactions with caseworkers, nursing, and physicians to identify barriers and explore alternatives to discharge delays, and formulating appropriate discharge plans that meet patient needs and MCO standards. Providing ongoing education for patients, staff, families, and physicians on managed care changes, facilitating quarterly in-services, and orienting new employees are also key functions. Maintaining an active knowledge base of managed care organization (MCO) standards, demonstrating awareness of preauthorizations for prescription medications and patient transportation, and attending seminars for updated information are required. The role also involves collaborating with the manager and physicians to assure proper utilization of patient days, accurate documentation in the Midas System, communicating pertinent issues to the billing department, and actively collecting data for performance improvement activities. Other related duties as assigned.

Requirements

Graduate of an accredited Nursing Program required.
One (1) year clinical experience, preferably in behavioral health acute inpatient setting.
Strong leadership ability, good organizational skills, independent and critical thinking skills, sound judgment, and knowledge of legal aspects and liability of nursing practice.
Knowledge of Payor/Insurance Benefits
Functional Skills on PC and Related Software (Microsoft Office)
Knowledge of basic Office Equipment such as copier, fax machine, etc.
Excellent communication, interpersonal and organizational skills
Analytical problem-solving skills, sound judgment; excellent oral and written communication skills, must be able to function in a team environment.
Ability to communicate with all members of the health care team
Ability to multi-task and prioritize assignments
Strong organizational and time management skills; ability to work independently and in a team setting.
Excellent negotiation skills.
Strong analytical, data management.
Current working knowledge of utilization management, case management and discharge planning.
Current working knowledge of community resources, post-acute services.
Current licensure to practice as a Registered Nurse in the State of Pennsylvania required.
Current Basic Life Support (BLS) approved curriculum of the American Heart Association (CPR and AED) program required.
PA Act 153 Clearances with renewal.

Nice To Haves

Bachelor’s Degree in Nursing preferred.
Recent Case Management experience preferred.
Three (3) years’ experience in the field of psychiatric nursing or social work.

Responsibilities

Completes initial utilization review for medical necessity for an assigned patient population.
Initiates assessment within 24 hours of admission or next business day.
Applies Interqual criteria for severity of illness/intensity of service indicators/medical necessity criteria as appropriate.
Recognizes and progresses the plan of care when an alternative level of care is appropriate.
Conducts continued stay reviews by monitoring patient's response to treatment and resource utilization.
Collaborates with Attending Physician and healthcare team to facilitate the progression of the plan of care.
Completes initial and continued stay reviews in a timely manner, in accordance with various payor contracts and guidelines.
Cognizant of payor requirements for all patients in assigned caseload.
Responsible for accurate and timely documentation in recognized data bases to support Clinical Resource Management components for each patient in assigned caseload.
Initiates contact with Attending Physician on all cases that do not meet SI/IS indicators to clarify plan of care.
Educates physicians and other members of the healthcare team on the application of Interqual criteria to support an Acute Level of Care and provide alternatives to acute care as appropriate.
Encourages and coaches the Attending Physician to participate in third party payor appeal process when necessary.
Notifies the Manager of all real or potential cases in which an adverse determination has been rendered or is anticipated by the payor.
Identifies and facilitates transition to an alternate level of care.
Assesses, plans, and facilitates appropriate discharge plans for assigned patient caseload with collaboration from the patient/family, physician, and other members of the healthcare team.
Coordinates alternate levels of care based on the patient’s current needs and availability of healthcare resources.
Creatively resolves complicated disposition issues, utilizing community resources with the integration of the patient's available benefits to achieve a positive outcome.
Provides information for appropriate referrals to patients and their families, and provides counseling on a limited basis.
Maintains patient rights by adhering to HIPPA, Freedom of Choice, Rights of Reconsideration, and other regulatory agency requirements.
Exhibits active positive communication/collaboration with appropriate internal and external agencies.
Daily interactions with case workers, nursing and physicians to identify barriers and explore alternatives that may contribute to a delay in discharge.
Formulate appropriate discharge plans for patients that meet patient needs and MCO standards.
Provide ongoing education for patients, staff, families, and physicians on managed care changes.
Facilitate quarterly in services to staff.
Orient new employees to their role in a managed care environment.
Maintain an active knowledge base of managed care organization (MCO) standards.
Demonstrate awareness of preauthorization’s for prescription medications and patient transportation.
Attends seminars as needed to obtain updated information.
Collaborates with manager and physicians as needed to assure proper utilization of patient days.
Accurate documentation in Midas System.
Communicates pertinent issues on patients to billing department.
Actively collects data for performance improvement activities.
Other related duties as assigned.
Actively promotes a Lean work culture by performing team member duties to encourage consistent use of LEAN principles and processes, including continually seeking work process improvements.
Recognizes the necessity of taking ownership of one’s own motivation, morale, performance and professional development.
Strives for behavior consistent with being committed to Excela’s missions, vision and values.