Case Manager (Full-Time)

Larkin Community Hospital•South Miami, FL

3d•Onsite

About The Position

The Case Manager will perform and document patient assessments, check prior authorizations, and conduct concurrent reviews to obtain insurance authorization for patient admissions and continued stays. This role involves indicating the appropriate level of care, establishing criteria for medically necessary services, and developing a comprehensive plan of care from admission to discharge. The Case Manager will promote efficient and cost-effective use of services, curtail inappropriate services, encourage standardization of medical practices, and enhance healthcare quality. Responsibilities include managing lengths of stay, evaluating patient readiness for discharge, developing discharge plans, and coordinating with physicians. The role also involves managing transfer procedures, guardianship processes, and educating patients/families about discharge plans and available resources. Participation in Performance Improvement (PI) programs, scheduling Peer-to-Peer reviews, and proactively resolving issues that could lead to denials are also key aspects of this position.

Requirements

Previous C.M. Experience
Substantial clinical experience
Bachelor's degree (required)
Familiarity with Medhost electronic medical records
Extensive medical knowledge
Self-driven (work and education)
Keeps knowledge up to date by reading literature and participating in outside continued education meetings, training, and conferences
Working knowledge of regulatory agencies
Excellent human relations and communication skills (verbal and written) to maintain good rapport and effective working relationships with medical staff, nursing staff, and other ancillary department staff throughout the hospital
Excellent organizational skills and attention to detail
Ability to convey care plan to physicians and the medical team
Proficient with Microsoft Office Suite or related software.
Integrity
Knowledge navigating and using payer portals
Knowledgeable of Milliman Care and Interqual Guidelines

Nice To Haves

Masters (preferred)
Foreign Medical Graduate or Registered Nurse (preferred)
CCM (Certified Case Manager) (preferred)
ACM (Accredited Case Manager) (preferred)
Bilingual (English/Spanish) (preferred)

Responsibilities

Performs and documents patient assessment within 24 hours of admission
Checks prior authorizations initiative by admitting
Performs concurrent reviews
Contacting all HMO’s on a daily basis and provides clinical information to obtain insurance authorization for the patient’s admission and continued stay
Indicates the appropriate level of care and utilization of services needed
Establishes criteria for medically necessary services
Develops a plan of care for patients from admission to discharge.
Promotes the most efficient and cost-effective use of services
Curtails the performance of inappropriate and/or duplicate services
Encourages standardization of medical practice patterns
Enhances the quality of healthcare
Performs concurrent reviews for patients to ensure that extended stays are medically justified and are documented in patient's medical records.
Calculates and manages the lengths of stay and continued-stay days for patients.
Evaluating the patient’s condition and readiness for discharge planning
Develops discharge plans
Communicate and assist the physicians in the planning and coordination of patients discharge planning
Management of transfer procedures
Management of the guardianship process
Able to discuss and educate patient/family regarding discharge planning and resources available after discharge. Clearly specifies all the information discussed with the patient and/or family regarding the patient’s discharge plan.
Participates in PI programs through the identification of opportunities for improvement, data collection, evaluation of findings, improving the process, applying knowledge and incorporates into practice
Scheduling Peer-to-Peer reviews with payors
Proactively identifying and resolving issues that could lead to denials