Case Manager SE

Advocate Health • Bermuda Run, NC

4d • $38 - $57

About The Position

The Case Manager provides care coordination, utilization management, and discharge planning for patients at Wake Forest Baptist Medical Center. The role conducts assessments, establishes plans, and coordinates interventions with patients, families, and the healthcare team to support patient goals, safe transitions, and timely progression of care. It provides continuity of care in compliance with regulatory standards and arranges relevant services based on assessed needs.

The Case Manager coordinates referrals, documents discharge planning and utilization review activities, conducts concurrent and retrospective reviews, and supports utilization management work such as payer updates, denial activity, and avoidable-delay management. The position collaborates with Social Work, medical staff, hospital departments, community agencies, and other care management teams, and serves as a resource on admission status, acute care criteria, care coordination, discharge planning, and regulatory requirements. The role also requires providing age-appropriate care in accordance with departmental policies and procedures.

Requirements

• Graduate of a Board of Nursing-approved nursing education program (RN).
• Current RN license or temporary license as a Registered Nurse Petitioner in the state where the employee works and resides; alternatively, meet home-state licensure requirements when declaring an NLC state as the primary state of residency, or hold a current or temporary RN license in a non-NLC state where applicable.
• Typically requires 3 years of related nursing experience.
• Clinical experience within the assigned population.
• Extensive knowledge of disease processes and clinical outcomes.
• Ability to prioritize and organize work.
• Effective communication skills.
• Ability to use critical thinking and make timely decisions.
• Ability to navigate the Electronic Health Record.
• Basic proficiency with MS Office products.
• Knowledge of Medicare A and B guidelines.
• Knowledge of Managed Care program requirements and implications.
• Ability to apply elements of Utilization Management programs.

Nice To Haves

• Bachelor of Science degree in Nursing (BSN).
• Case Management experience or background.
• Strong critical thinking and analytical skills.
• Appropriate professional certification, preferred within 3 years of hire.

Responsibilities

• Conduct complete assessments, establish appropriate plans, and initiate interventions within desired timeframes.
• Collaborate and negotiate with patients, families, and the healthcare team to support patient and organizational goals, care needs, choice, satisfaction, and discharge transitions.
• Involve patients, families, and the team in decision-making throughout the hospital stay, using patient and family strengths in problem-solving.
• Provide continuity of care and compliant discharge planning by coordinating relevant options and services and supporting smooth patient transfers.
• Provide case management services related to healthcare levels, finances, housing, family discord, or illness adjustment within the department's scope.
• Manage family dynamics and crisis situations professionally and promptly; use community resources and educate patients and families about accessing and using services.
• Initiate internal and external referrals to support timely care progression and transitions.
• Document discharge planning interventions and utilization review activity according to department and medical center standards.
• Conduct and document accurate, timely concurrent and retrospective reviews using approved criteria.
• Communicate with the healthcare team and partner with Social Work and unlicensed support personnel to establish and implement safe plans of care.
• Participate actively in the MDR and work with medical staff, hospital departments, and ancillary services to resolve discharge barriers, expedite care, and implement and report care coordination, discharge planning, and utilization management activities.
• Collaborate with managers, physicians, medical directors, advisory groups, and treatment teams on physician practices and patient care plans; refer cases to a physician advisor as needed.
• Maintain knowledge of healthcare regulations, reimbursement, length-of-stay impacts, and community resources.
• Complete utilization management activities, including providing clinical updates to payers or external review organizations, collecting data, coordinating denial activity, supporting UM activity, and managing avoidable delays.
• Deliver CMS regulatory notices within established timeframes, according to site guidelines.
• Develop and maintain relationships with community agencies and networks, representing Advocate Health Care positively and working collaboratively to meet patient and family needs.
• Collaborate with Advocate Ambulatory Care Management and Continuing Health to meet shared goals and outcomes.
• Educate and serve as an expert resource to medical and hospital staff on admission status, acute care criteria, utilization management, care coordination, discharge planning, and applicable regulatory requirements.
• Demonstrate the knowledge and skills needed to provide care appropriate to patients' ages and developmental needs, in accordance with departmental policies and procedures.

Benefits

• Paid Time Off programs.
• Medical, dental, vision, life, and short- and long-term disability benefits.
• Flexible Spending Accounts for eligible healthcare and dependent care expenses.
• Adoption assistance and paid parental leave.
• Defined contribution retirement plans with employer match and other financial wellness programs.
• Educational Assistance Program.
• Competitive compensation, with potential premium pay, incentive pay for select positions, and annual performance-based increases.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level