Case Manager - RN

UHS•Aiken, SC

15d•Onsite

About The Position

The Case Manager is responsible for admission, concurrent and retrospective medical review of all patient populations for documentation of appropriateness of admission and continued stay. This position requires close collaboration and communication with payers to reduce risk of denials by continued management of all assigned cases from admission to discharge. Responsible for managing assigned patient population for progression of medical management and readiness for discharge. This includes the initiation of interventions to reduce and eliminate avoidable days, opportunity days and delays in care; works in collaboration with interdisciplinary team members internal and external to the organization; participates in process improvement and evaluation process related to the management of patient care and resource utilization. Responsible for working in close collaboration with the assigned SW/DCP on the floor to ensure a safe and timely transition of care, with the goal of management of LOS and utilization of resources on their assigned units. Performs discharge planning as needed to ensure timely transition of care of all patients on the assigned unit.

Requirements

Diploma or associates degree from an accredited Registered Nursing program.
Minimum of 3 years experience in acute-care hospital or related setting; previous utilization review or case management experience.
SC RN license or compact state license.
Knowledge of private insurance, Medicare criteria for hospitalization, understanding of healthcare financial systems, benchmarking practices; Experience in facilitating change through interdisciplinary collaboration; computer skills.

Nice To Haves

BSN preferred.

Responsibilities

Performs chart reviews (admission, concurrent and retrospective, as necessary) for all payor sources in order to certify appropriateness of admission, accurate status, continued stay and reduce denial risks.
Follows department processes for management of denied cases, refers these cases for Peer to Peer or for VH appeal. Sends updated clinical to request reconsideration when appropriate.
Follows department process for referrals to VERSALUS HEALTH for all OBS cases and follows up after review to facilitate order status changes as appropriate.
Monitors all patients on their assigned floor for progression of care and clinical readiness for discharge and works with their SW/DCP partner to limit delays in transition of care by performing discharge planning as needed in the assigned unit.
Works in collaboration with partner, nursing, and other members of the Interdisciplinary team to anticipate discharges for the next day and provides this information to clinical staff at the end of each day.
Maintain strong relationship with insurance companies to share clinical information for payment authorization and limit risk of denials. Follows and continues to work denied cases in an effort to overturn denials while patients are still in house.
Collaborates with members of the healthcare team to ensure documentation supports admission or continued stay when documentation is not clear to ensure appropriateness of acute hospital stay.
Identifies and documents, and manages avoidable hospital days according to defined criteria and initiates appropriate intervention as necessary to minimize discharge delays.
Educates medical staff, nursing and other members of the healthcare team regarding utilization of hospital days and resources.
Identifies and makes referrals to other departments such as Infection Control, Wound Care, Nutrition/Dietary, and Peer Review as appropriate.
Collaborates with Medical staff and other departments as appropriate to facilitate development of clinical practice guidelines for designated patient groups.