Lead Case Manager Nurse

WVU Medicine

21h•$73,715 - $110,573•Onsite

About The Position

Functions as a lead team member and fosters a positive, mentoring work environment. Comprehensively plans for targeted patient populations and performs resource management, including denial management, utilization management, ensuring access to the appropriate level of care, discharge planning, care facilitation, and referrals to other levels of care. Works collaboratively with the multidisciplinary care team to facilitate desired treatment outcomes and provides oversight of staff. This role provides staff support, expertise, and leadership; helps coordinate workflow, assignments, and schedules; and manages transition and discharge planning for assigned patients. The nurse collaborates with patients, families, physicians, multidisciplinary teams, and post-acute providers; monitors progress and supports patient-focused, high-quality, efficient, and cost-effective care. The role also includes patient and staff education, referrals to post-acute services, documentation, assistance with advance care planning documents, and coordination of financial and other resources. The position performs clinical reviews, applies utilization criteria to assess medical necessity and level of care, supports authorization and reimbursement certification, addresses payer issues, and educates hospital staff and physicians about payer regulations and managed care principles. The job is scheduled for 40 hours per week and is based at Garrett Regional Medical Center in Oakland, Maryland. The stated compensation range is $73,715.20–$110,572.80, based on 100% FTE; salary is prorated if hired at less than 100% FTE.

Requirements

Current Registered Nurse license issued by the state where services are provided, or a current multistate Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
Seven years of clinical experience.
Knowledge of patients’ current medical insurance coverage and limitations, and precertification requirements for durable medical equipment, post-acute placements, infusions, transfers, and related services.
Knowledge of relevant scientific principles, established standards of care, and/or research findings.
Knowledge of procedures and techniques involved in administering routine and special treatments to patients.
Knowledge of and appropriate application of the nursing process.
Ability to meet the physical demands of the role, including patient handling and heavy work: exerting over 100 pounds of force occasionally, up to 50 pounds frequently, and/or up to 20 pounds constantly.
Normal-range hearing and visual acuity; ability to perform night driving as necessary for patient care.

Nice To Haves

Bachelor’s degree in Nursing (BSN).

Responsibilities

Provide support, expertise, and leadership to staff.
Help coordinate workflow, work assignments, and schedules.
Manage transition and discharge planning for assigned patients in a timely manner.
Collaborate with multidisciplinary team members to facilitate transition and discharge for the designated caseload.
Monitor patient progress and intervene as appropriate to help ensure care plans and services are patient-focused, high quality, efficient, and cost-effective.
Educate staff, physicians, patients, and families as needed to support effective transition planning.
Meet with patients and/or families to assess needs and develop individualized transition and discharge plans in collaboration with the physician team.
Communicate complex family dynamics that may affect patient care and transition or discharge planning to the multidisciplinary team and post-acute providers, when applicable.
Initiate and facilitate referrals to post-acute services, including home care, durable medical equipment, hospice, long-term acute care, acute rehabilitation, and skilled nursing facilities.
Communicate transition and discharge plan information to the multidisciplinary team, patient, and family.
Document interactions with patients and families, transition and discharge planning activities, and progress in a timely and comprehensive manner according to departmental policy.
Assist patients and families with medical power of attorney, health care surrogate, and advance directive documents.
Collaborate on resource and financial management, including referrals or coordination for financial assistance, entitlement programs, and patient benefits.
Use quality screens in the electronic record to identify potential issues, including avoidable delays and readmissions.
Complete clinical reviews for patients.
Apply approved utilization criteria to assess medical necessity for admissions and continued stays, and document findings according to departmental standards and policies.
Screen for appropriate authorization and level of care.
Facilitate covered-day reimbursement certification for assigned patients; discuss payer criteria and issues with clinical staff, including peer-to-peer discussions, and follow up with payers to resolve problems as needed.
Educate hospital staff and physicians about payer regulations and managed care principles to help prevent denials.
Foster the integration of staff and/or students into the healthcare team.
Perform nursing duties involving frequent walking, standing, stooping, kneeling, reaching, pushing, pulling, lifting, grasping, and feeling.
Lift, move, and position patients of all weights, with varying assistance, on a regular and recurring basis.