Case Manager - RN, Our Lady of the Lake Health

FMOLHS•Baton Rouge, LA

About The Position

The Case Manager 1 directs utilization review of patient charts and treatment plans, assessing quality of care and whether treatment meets applicable criteria for patients in an assigned department. The role specializes in reviewing information relevant to its assigned area and relies on education, experience, professional training, and judgment. It operates with minimal supervision and allows a wide degree of creativity and latitude. The Case Manager works with treatment teams and healthcare partners to support appropriate care, utilization review, reimbursement, and discharge planning. The role may focus on areas such as Case Management, Geriatrics, Mental and Behavioral Health, or Home Health; not all accountabilities apply to every specialty area.

Requirements

Three years of experience in general or specialty nursing practice.
Associate's degree.
Current and unrestricted Louisiana State License as a Registered Nurse (RN).

Responsibilities

Contribute to cost effectiveness and efficiency, apply benefit-system and cost-benefit awareness, and use a continuum-of-care approach to maximize financial outcomes for assigned patients.
Assist with developing, monitoring, and analyzing annual financial goals for the targeted population.
Understand the capabilities of outside referral sources, healthcare delivery systems, and payor prior-approval requirements for admissions, procedures, and continued stays.
Meet with treatment teams to provide utilization review information, discuss continued-stay and discharge issues, evaluate financial resources, and assess documentation and appropriate levels of care.
Use utilization review techniques in collaboration with physicians, third-party payors, and federal and local agencies to help prevent payment or day denials.
Serve as a resource to unit personnel on utilization and case management problems, and communicate identified issues to appropriate personnel to support departmental efficiency.
Collaborate with the healthcare team to optimize reimbursement, coordinate discharge planning, support cost-effective quality care, assess referral and alternate-level-of-care needs, and track and report avoidable days.
Coordinate service delivery, assess physical and mental impairment, and collaborate with the healthcare team to develop treatment and discharge plans based on patient clinical information.
Evaluate the quality of necessary medical services, apply criteria to determine medical necessity of admission, and work with physicians to facilitate assignment to an appropriate level or alternative of care.
Provide timely information to third-party payors, coordinate denials and appeals, and help ensure appropriate financial outcomes and levels of care.
Use community resources, understand the ADA and other federal legislation affecting people with disabilities, and help establish client support systems.
Follow departmental and hospital policies and procedures, including safety, quality assurance, and infection control standards.
Maintain current expertise through relevant seminars, workshops, professional conferences, and affiliations with national and state professional organizations.
Perform other duties as assigned or requested.