CASE MANAGER

Independence Health System•Butler Township, PA

About The Position

The Case Managers are experienced Registered Nurses who interact with the patient, families, physicians and other members of the interdisciplinary team to facilitate quality and cost effective care. An essential component to all roles includes the evaluation of medical necessity and intensity of service of each admission to arrive at decisions regarding medical appropriateness for the requested level of care. Communicates with the various payers/insurance companies to authorize services and ensure appropriate reimbursement to the facility. Actively promotes collaboration among all interdisciplinary care providers, including physicians to effectively identify needs for continued inpatient care or appropriate alternate levels of care. There is coordination to affect an appropriate discharge plan with the Case Managers ensuring arrangements of placement/services upon discharge. Assist to identify and make efforts to correct delays in services, fragmentation of care and gaps in communication. Patient outcome monitoring and participation in continuous performance improvement are also requirements in this role.

Requirements

Graduate of a Registered Nurse Program
Current PA RN license
Three years recent clinical experience.
Excellent communication skills and skills in customer service.
Demonstrates leadership ability.
Commitment to the delivery of quality patient care with the ability to develop and maintain effective, professional relationships with all members of the health care team.

Nice To Haves

Bachelor Degree in Nursing
Healthcare Provider CPR
Managed care or previous Case Management/Utilization Review experience.

Responsibilities

Performs admission as well as continued stay review of designated cases through established decision support criteria (Interqual) accurately identifying Severity of Illness/Intensity of Service to determine appropriateness of admission and ensure appropriate reimbursement. Focuses on Observation cases to determine appropriate action/follow up necessary in relationship to medical necessity; i.e. discharge/transition to inpatient status. Demonstrates understanding and efficiency in physician referrals/tasking to EHR.
Provides clear documentation of selected medical necessity criteria as well as interventions and obtained authorizations. Demonstrates the ability to navigate the Navinet On Line Highmark process, the Allscripts case management module, Meditech and EMR.
Understands and applies the many reimbursement strategies of the various payers and makes appropriate decisions relevant to this information (i.e. per diem/DRG, case Rate, observation, etc). Completes all required authorizations/pre-certifications to ensure appropriate reimbursement to the facility.
Serves as an organizational collaborator for the patient to promote appropriate, efficient quality care. Collaborates with the Social Worker and health care team to ensure timely discharge planning; demonstrating efficiency in arranging for patient Post Discharge Needs: home infusion therapy, medications, DME, placement, transportation etc.
Remains knowledgeable and participates in ongoing performance improvement activities within the department as well as on an organizational level; CoP (Conditions of Participation); MEIM, Freedom of Choice; Delay Days, LOS/Readmission Reduction initiatives, HF clinic referrals, identifying barriers to discharge, fragmentation in patient care, etc.
Completed mandatory education, annual competencies and department specific education within established timeframes.
Completed annual employee health requirements within established timeframes.
Maintained license/certification, registration in good standing throughout fiscal year.
Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self. Identifies and works to reduce potentially unsafe patient care or other safety practices.
Adheres to regulatory agency requirements, survey process and compliance.