Case Manager

UNC Health•Kinston, NC

9d•Onsite

About The Position

The Case Manager coordinates the hospital’s utilization review activities, completes CQI monitors for the RM Committee, and assures compliance with Federal, State, and third-party insurance guidelines. The role coordinates discharge planning, patient teaching, and related activities to support discharge to nursing facilities or successful community re-entry. The Case Manager reviews admission and continued-stay appropriateness, obtains patient precertification, follows up on payer denials and appeals, and consults physicians when medical necessity is questioned. The role interviews patients and families, documents psychosocial and other relevant circumstances, makes referrals, assesses needs, and develops plans. It also coordinates patient education and discharge planning with patients, families, physicians, interdisciplinary teams, and community agencies. The position serves as a resource to families, staff, community agencies, and physicians; supports staff learning; participates in relevant seminars, in-service education, and hospital committees; and collaborates with health professionals to provide comprehensive care. The Case Manager works autonomously, prioritizes according to patient needs, follows hospital and department policies, and takes responsibility for performance and professional development.

Requirements

Graduate of an accredited school of nursing or be a Medical Social Worker; a baccalaureate degree in a human services area is accepted.
Three to four years of experience in a hospital, nursing home, or community agency.
Obtain Case Manager Certification within five years.
Certification by the American Board of QA/UR or InterQual, certification in Social Work, or licensure in North Carolina as an RN or LPN.
Knowledge and skills in InterQual ISD-A criteria.
Good interpersonal and communication skills.
Understanding of patient care needs according to developmental stages for various age groups.
Knowledge of State and Federal regulations regarding admission and reimbursement for Medicare, Medicaid, and other payor sources.
Reading and mathematics skills.
Ability to work autonomously.

Responsibilities

Monitor utilization review activities and resource utilization, including reviewing admission and continued-stay appropriateness.
Obtain patient precertification, follow up on payer denials through the appeal process, and consult physicians or physician consultants when medical necessity is questioned.
Complete chart reviews within 24 working hours and obtain precertification within 48 working hours.
Interview patients and families; document psychosocial, financial, cultural, domestic violence, and protective services circumstances; make referrals as needed; assess needs; develop plans; and provide brief counseling.
Complete case findings, assessments, and treatment plans according to policy.
Coordinate and promote patient teaching, including education and implementation of AMD and DNR; document education as needed and identify appropriate educational resources.
Coordinate learning activities with multidisciplinary team members and include patients, families, or significant others in patient education plans.
Coordinate discharge planning among community agencies, the interdisciplinary team, patients, families, and physicians.
Identify appropriate levels of care for nursing home placement or extended care; complete FL2 and the PASARR approval process.
Maintain working knowledge of financial and community resource regulations and availability, and coordinate continuity of care to facilitate transition from LMH.
Serve as a resource for families, staff, community agencies, and physicians; assist with staff learning needs; participate in job-related seminars, in-service education, and hospital committees addressing managed care or length of stay.
Collaborate with health care professionals to provide comprehensive quality care to patients and families.
Work autonomously, complete assigned tasks, seek additional responsibilities and learning experiences, prioritize according to patient needs, follow hospital and department policies, manage time appropriately, and pursue professional growth.