Case Manager - RN

Independence Health System Careers•Greensburg, PA

About The Position

The Case Manager - RN supports safe, effective, patient-centered care coordination and transitions for Independence Health System patients. The role assesses, plans, implements, coordinates, monitors, and evaluates care options with patients, families, caregivers, providers, and the broader health care team. It manages transitions between care settings, facilitates appropriate discharge, and works to reduce readmissions and poor health outcomes. The Case Manager applies clinical reasoning and critical-thinking skills to complex and high-risk cases, advocates for unbiased and culturally competent care, and ensures care decisions reflect patients’ values, needs, preferences, and choices. The role also provides crisis management, connects patients with interventions and community resources, supports patient and family education, and resolves problems through multidisciplinary teamwork. In discharge planning, the Case Manager coordinates alternate levels of care according to patient needs and resource availability, addresses complex disposition issues, provides referral information, and involves patients and families in goal setting. The role upholds patient rights and regulatory requirements and collaborates with the Denial Management Specialist on appeals, grievances, medical necessity review, correspondence, data collection, and reimbursement issues. In utilization review, the Case Manager completes initial and continued-stay reviews for an assigned patient population, applies InterQual criteria, monitors treatment response, length of stay, and resource utilization, and collaborates with physicians and the health care team to progress plans of care. The role documents review findings and case management activity in recognized databases, tracks avoidable or delay days in the Midas System, and communicates payor benefit limits and requirements as needed. The position has no direct supervisory responsibilities, but serves as a coach and mentor to other department positions. Scheduling is based on operational need and may include rotating shifts, standby, or on-call work. Local travel between Independence Health locations may be expected.

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.
Act 33 clearance with renewal, Act 34 clearance with renewal, and Act 73 FBI clearance with renewal.
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 with 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.

Nice To Haves

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

Responsibilities

Maintain professional and technical knowledge through education, publications, professional networks, and professional societies.
Promote quality and safety by following therapeutic standards, nursing practice requirements, infection-control policies, medication procedures, and confidentiality requirements.
Document and communicate patient care, care-team actions, irregularities, and ongoing needs, including through Nurse Knowledge Exchange techniques.
Implement standard work, clinical protocols, and patient care pathways.
Assess, plan, implement, coordinate, monitor, and evaluate care options with patients, families, caregivers, providers, and the health care team.
Coordinate safe and effective transitions of care, including comprehensive planning, targeted outreach, timely information transfer, and appropriate discharge to reduce readmissions and poor outcomes.
Provide crisis management and connect clients with appropriate interventions and community resources.
Educate patients and families about conditions, medications, self-care, and care goals, and provide emotional, psychological, and spiritual support.
Advocate for patients and ensure care coordination reflects their values, needs, preferences, and choices, including the choice to self-direct care.
Resolve patient problems using multidisciplinary team strategies and maintain cooperative relationships through communication, rapport-building, and quality-improvement participation.
Coordinate alternate levels of care based on patient needs and available resources, resolve disposition issues, provide referral information, and involve patients and families in goal setting.
Maintain patient rights and comply with HIPAA, Freedom of Choice, Rights of Reconsideration, QIO, and other regulatory requirements.
Collaborate with the Denial Management Specialist on concurrent and retrospective appeals and grievances, including medical record review, physician consultation, correspondence, file maintenance, and related data collection.
Consult with the Denial Management Specialist, department Manager, and Physician Advisor or designee to address adverse determinations and denials.
Collaborate with Patient Accounting and ancillary departments to resolve payor reimbursement issues in a timely manner.
Complete initial utilization reviews for medical necessity, initiating assessment within 24 hours of admission or the next business day.
Apply InterQual severity-of-illness and intensity-of-service indicators and refer cases that do not meet initial criteria for second-level review.
Conduct continued-stay reviews, monitor treatment response, length of stay, and resource use, and collaborate with the attending physician and health care team to progress the plan of care.
Complete reviews and documentation in a timely manner according to payor contracts and guidelines; communicate plan benefit limits and availability as needed.
Track and trend avoidable or delay days in the Midas System and maintain accurate case-management data in recognized databases.
Ensure equipment operation by completing preventive maintenance requirements, following manufacturer instructions, troubleshooting malfunctions, requesting repairs, maintaining inventories, and evaluating new equipment and techniques.
Serve as a coach and mentor to other department positions; perform other duties as assigned.