Registered Nurse (RN) - Case Manager

Lifepoint Health • Johnstown, PA

2h • Onsite

About The Position

The Utilization Management RN Case Manager (UM-RNCM) works under the direction of the Case Management Manager and plays a critical role in ensuring accurate clinical documentation and regulatory compliance. The UM-RNCM performs initial clinical reviews of assigned patient records to validate Severity of Illness and Intensity of Service using industry-standard criteria (MCG). Cases that do not meet criteria are escalated to Physician Advisors, with ongoing follow-up to ensure appropriate utilization and compliance. This role is responsible for communicating clinical information to managed care organizations to secure authorization for services and reimbursement. The UM-RNCM also ensures accurate patient status throughout the hospital stay and collaborates closely with physicians to address and resolve any denial determinations.

Requirements

• current state RN license
• associate or bachelor’s degree from an accredited nursing school
• BLS Certification
• 3 years experience in acute care as a Professional Nurse or RN experience with significant acute care hospital Case Management experience

Nice To Haves

• Previous case management experience preferred
• Case management certification, CP preferred

Responsibilities

• Skilled in Case Management functions and Care Coordination
• Utilizes Interqual or the 2MN rule to determine status for all patients assigned an acute care bed.
• Reviews medical records and provides accurate clinical information to payers for authorization.
• Collaborate with interdisciplinary team to facilitate progression of care and resource utilization.
• Proactively interacts with patients and families during the admission process to set expectations for the course of stay and length of stay.
• Proactively analyzes information from the care team to support inpatient admission.
• Assesses, identifies, and intervenes to reduce the risk of barriers that will interfere with the transition of care.
• Facilitates optimal care transition to reduce avoidable readmissions.
• Follows the Case Management policy & procedure for utilizing Physician Advisors.
• Interacts with attending physicians, physician advisor and department chairs about any identified quality issues and utilization issues.
• Leads Interdisciplinary Discharge Planning Rounds (IDTs) to determine appropriate concurrent care planning, resource utilization and appropriate post acute level of care determination.
• Identifies and documents avoidable days and intervenes promptly to remove identified barriers.
• Follows CMS & regulatory requirements for Case Management processes.
• Coordinates concurrent denial/appeal- (peer to peer) process for assigned cases.
• Assumes on-call and weekend duties as assigned.
• Assist floor(s) with transportation barriers during working hours.

Benefits

• Multiple levels of medical, dental and vision coverage for full-time and part-time employees.
• Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off.
• Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match.
• Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs).
• Ongoing learning and career advancement opportunities.

What This Job Offers

• Career Level: Mid Level
• Education Level: Associate degree