RN Care Manager - Casual

IRMC Career•Indiana, PA

6d•Onsite

About The Position

This role involves working with nursing and case management leadership to achieve organizational goals and patient care initiatives. The RN Care Manager will determine patient insurance eligibility, status, and benefit coverage, utilizing medical necessity criteria to assess the appropriateness of admission and continued stay. Key responsibilities include ensuring efficient patient progression through care and treatment, optimizing resource utilization and cost-effectiveness through ongoing case management and communication with the healthcare team. The role also involves timely and appropriate communication with medical staff, offices, and ancillary departments regarding patient referrals, authorizations, and medical necessity. The position requires identifying issues in concurrent cases for focus studies to assess impact on cost and reimbursement, analyzing pre-established outcomes with report-specific data, and acting as a liaison to pre- and post-hospital care providers and community health resources. Education for patients, families, and staff on provider guidelines, discharge planning, and resource information is also a part of this role. Additionally, the RN Care Manager will participate in multi-disciplinary discharge planning and committee meetings, document patient information using a software system via laptop, and play a role in identifying risk, quality, and infection control issues through concurrent chart review. Compliance with hospital policies on safety, infection control, and performance improvement, along with a thorough understanding of third-party payer systems related to utilization management and discharge planning, are essential. Adaptability to continuous change and practical knowledge of the nursing process and continuity of care are also required. Please note that this job description is not exhaustive and duties may change.

Requirements

Diploma Program, Associate’s, or Bachelor’s Degree in Nursing or other health-related field
3-5 years medical/surgical nursing, ED experience preferred
Case Management experience in Acute, Psychiatric, or ED
Medicare/MA/MCO and third party reimbursement
Interqual or Milliman experience
Office Suite experience
Licensure as Registered Nurse in Pennsylvania by State Board of Nursing Examiners

Nice To Haves

Case Manager Certification preferred

Responsibilities

Working with nursing leadership and case management leadership to fulfill organizational goals and patient care initiatives.
Determining patient insurance eligibility, status, and benefit coverage with each patient encounter.
Utilizing medical necessity criteria specific to the managed care/insurance plan to determine appropriateness of admission and continued stay.
Assuring that the patient moves efficiently through all aspects of care and treatment with optimal utilization of resources and cost through ongoing case management and communication with all members of the healthcare team.
Effectively communicating in a timely, interactive, and appropriate manner with medical staff, offices, and required ancillary departments regarding patient referral, authorization, and medical necessity and criteria.
Identifying issues during concurrent cases to be targeted for focus study to determine impact on cost and reimbursement.
Analyzing and evaluating pre-established outcomes with report-specific data extracted from the Case Manager daily work.
Acting as a liaison to pre-post hospital care providers along with community health resources to ensure continuation of patient care.
Providing education to patients, families, and hospital staff related to provider guidelines, discharge planning, and resource information as appropriate.
Participating in multi-disciplinary discharge planning meetings along with attending committee and task-oriented meetings as assigned.
Documenting and maintaining accurate and pertinent information related to each concurrent patients through the utilization of a software system via laptop computer.
Playing an integral role in the identification of risk, quality, and infection control issues through ongoing, concurrent chart review and reporting.
Complying with hospital policies and procedures on safety, infection control, and performance improvement.
Utilizing thorough understanding of third party payer systems as they relate to utilization management and discharge planning.
Adaptable to continuous change.
Utilizing practical knowledge of the nursing process and continuity of care.