Case Manager - PRN

Performs all aspects of Utilization Review/Discharge Planning/Social Service/Patient Representative, along with review of documentation.  Must recognize the complex interrelationships between the physical, emotional, social and economic factors that impact patient's well being.  Knowledgeable regarding resources which may be beneficial for the patient during the pre-, current, and post hospitalization period. Will conduct a concurrent review of every hospital admission to look for medical necessity and ensure the patients are admitted under the appropriate status.  Initiate conversations with Physician to educate and ensure documentation is complete to capture level of severity and complexity of care.

• Interviews inpatients, outpatients and families to access discharge planning.
• Provides direct intervention to patients as individual needs are identified along with psychosocial support for patient and families.
• Established discharge priorities and formulates a functional individualized discharge plan with patient/families.
• Makes appropriate referrals by utilizing available hospital and community resources.
• Assists in coordinating the patient’s care with other involved departments in order to facilitate the patient’s discharge needs.
• Functions as a resource person for patients/families, staff and physicians.
• Collects necessary admission and continued stay information on all patients and when necessary communicates the information to the appropriate review organizations pursuant to hospital policies and procedures.
• Conducts chart reviews.
• Presents outlying cases at UR Committee.

• Concurrent documentation reviews will be performed throughout the patients stay to ensure ongoing medical necessity and that treatment is provided at the correct level of care.
• Participates in Patient Care Conference to ensure an effective plan of care.
• Ensures efficient utilization of services throughout the patient’s stay.
• Educates patients/family/caregiver on medical necessity and appropriate level of care and alternatives for care as needed.
• Serves as a resource to hospital staff on medical necessity and appropriate level of care.
• Assists finance department with denials, recovery audits and other payer issues.
• Maintain a positive work environment and support the overall team.
• Work independently and prioritize efficiently.
• Utilize Milliman Care Guidelines as a guide to assist determining medical necessity and admission status.
• Attend UR committee meetings.
• Maintain confidentiality.