CASE MANAGER - RN

Independence Health System•Greensburg, PA

About The Position

The Case Manager - RN coordinates patient care and transitions across healthcare settings to promote safe, effective, and positive outcomes. The role assesses, plans, implements, coordinates, monitors, and evaluates care options with patients, families, caregivers, providers, and the healthcare team. It supports complex and high-risk patients through evidence-based care coordination, crisis management, discharge planning, utilization review, and connection to community and post-acute resources. The Case Manager advocates for patient-centered, culturally competent, unbiased care that respects patient values, needs, preferences, and choices, while helping ensure care is delivered in the right setting and at the right time. The position collaborates with Denial Management and Utilization Review, conducts medical-necessity and continued-stay reviews, tracks avoidable or delayed days, and supports appeals, grievances, and payor reimbursement issue resolution. The role also documents care, maintains confidentiality and regulatory compliance, contributes to quality improvement, and serves as a coach and mentor to other department positions, without direct supervisory responsibilities. Incumbents may be scheduled according to operational needs, including rotating shifts, standby, or on-call work, and may travel locally between Independence Health locations.

Requirements

Graduate of an accredited Nursing Program.
Three years of clinical experience in healthcare or recent case management experience.
Current licensure to practice as a Registered Nurse in Pennsylvania.
Strong leadership ability, organizational skills, independent and critical-thinking skills, sound judgment, and knowledge of legal aspects and liability of nursing practice.
Ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience.
Proficient documentation skills.
Knowledge of payor and insurance benefits.
Functional skills using a PC and related software, including Microsoft Office.
Excellent negotiation skills and strong analytical, data-management, and PC skills.
Current working knowledge of utilization management, case management, and discharge planning.
Current working knowledge of community resources and post-acute services.
Act 33 clearance with renewal.
Act 34 clearance with renewal.
Act 73 FBI Clearance with renewal.

Nice To Haves

Recent acute care experience.
Bachelor’s Degree in Nursing.
Case Management Certification.

Responsibilities

Assess, plan, implement, coordinate, monitor, and evaluate care options with patients, families, caregivers, providers, and the healthcare team.
Coordinate safe and effective transitions of care, including comprehensive planning, targeted outreach, and timely transfer of information between parties.
Facilitate appropriate discharge and care flow to help prevent readmissions and poor health outcomes.
Coordinate alternate levels of care based on patient needs and available healthcare resources; resolve disposition issues using community resources and available benefits.
Provide appropriate referral information and limited counseling to patients and families as needed.
Maintain patient rights and comply with HIPAA, Freedom of Choice, Rights of Reconsideration, QIO, and other regulatory requirements.
Involve patients and families in goal setting and evaluation of care.
Collaborate with the Denial Management Specialist on appeals and grievances, medical record reviews for medical necessity, correspondence, accurate files, databases, and data collection on denials and delays.
Consult with the Denial Management Specialist, department Manager, and Physician Advisor or designee to address adverse determinations and denials.
Coordinate with Patient Accounting and other ancillary departments to resolve payor reimbursement issues in a timely manner.
Complete initial utilization reviews for medical necessity for the assigned patient population and initiate assessments within 24 hours of admission or the next business day.
Apply InterQual criteria for severity-of-illness and intensity-of-service indicators, referring cases for second-level review when initial medical-necessity screens are not met.
Conduct continued-stay reviews by monitoring patient response to treatment, resource utilization, length of stay, and ancillary resource use.
Collaborate with attending physicians and the healthcare team to progress the plan of care and recognize when an alternative level of care is appropriate.
Complete initial and continued-stay reviews promptly in accordance with payor contracts and guidelines; understand and communicate benefit limits and availability as needed.
Document accurately and promptly in recognized databases and track and trend avoidable or delayed days in the Midas System.
Use clinical reasoning and critical thinking to manage complex and high-risk patients, advocate for patients, and support conflict-free, unbiased, culturally competent care.
Provide emotional, psychological, and spiritual support to patients, friends, and families; teach patients and families about conditions, medications, and self-care skills.
Protect confidential information, document patient care, and communicate actions, irregularities, and continuing needs across nursing teams.
Follow therapeutic, infection-control, medication, controlled-substance, patient-safety, and regulatory standards; maintain a safe and clean work environment.
Maintain professional and technical knowledge through education, publications, professional networks, and professional societies.
Maintain cooperative relationships with healthcare teams, communicate information, respond to requests, and participate in continuous quality improvement and problem-solving.
Ensure equipment operation through preventive maintenance, troubleshooting, repair requests, inventory maintenance, and evaluation of equipment and techniques.
Serve as a coach and mentor to other positions in the department; perform other duties as assigned.