CASE MANAGER-CERT

Job Summary:

Case Manager plans, coordinates, develops, evaluates, and monitors the care of assigned group of patients to achieve quality cost-effective patient outcomes. Works collaboratively with interdisciplinary teams to identify services required to meet the patient/family needs throughout the continuum of care, while ensuring that appropriate resources are implemented in a timely manner. Meets with all new admissions to identify and discuss a proposed discharge plan and then follow the progress of the discharge plan until discharged. Set-up post discharge services such as home health, dual medical equipment, returned to nursing home, swing bed, etc. Attends daily care management team meetings. Assigns Working DRG length of stay on all new inpatient admissions. Demonstrates knowledge and skills to appropriately communicate and interact with the patients, families, and visitors while being sensitive to their cultural and religious beliefs.Provides case management to improve placement of patients in the most appropriate care setting. Collaborates with physician and registration staff regarding medical necessity and medical review policies to assist in validating appropriateness of admission, services, and continued stay and, if necessary, issue letters of non-coverage. Collaborates with registration staff and physician's office staff regarding physician orders for correct level of care assignment. Issues hospital notices as indicated such as Important Messages from Medicare and Medicare Outpatient Observation Notices. Reviews scheduled Medicare outpatient surgeries for compliance with the APC "Inpatient Only" listing. Collaborates with Physician Advisors or Chief Medical Officer and the attending physician for questioned admissions to ensure an expedited appeal process. Evaluates the use of observation bed services to ensure that patients are either admitted to a higher level of care or discharged in a timely fashion to decrease our potential loss of reimbursement. . Performs timely level of care reviews concurrently on assigned patients relative to the prospective payment system for Medicare, Medicaid, private payors, and other hospital utilization management applications. Is involved in utilization review activities as defined by Utilization Management. Performs timely level of care reviews to ensure that patients are placed in the correct level of care. Obtains authorization from third party payers timely as indicated. Consistently follow-up and update auto/cert information on an ongoing bases. Track denials/appeals and document on a consistent basis and then refer to Denial Management Coordinator. Functions as the central liaison between the Medicare QIO, review agencies, Business Services, Patient Financial Services, and other healthcare professionals affected by concurrent review, DRG assignment, the certification process, and discharge planning. Participates on various committees/ task forces as needed. Demonstrates the ability to obtain s working diagnoses, working procedure codes and a working DRG as needed. . Assembles, analyzes, monitors, and tracks data for reporting as designated by the Director.

Qualifications:

Education/Skills

Degree from an accredited non-online RN program required. Bachelor of Science in Nursing preferred.

Work Experience:

Three or more years of experience in clinical nursing required. Case Management and/or Utilization Management experience preferred.

Certification/Licensure:

Certification/ Licensure

Required

Timeframe

X

upon hire

Current license with MS State Board of Nursing.

Mental Demands:

Exceptional oral and written skills are required to relate effectively to hospital staff, physicians, physician office staff, and review agencies. The individual must have the ability to type and be familiar with the rules of spelling, grammar, and punctuation. The individual must have the ability to use a copier, telephone, and personal computer. Workable knowledge of DNV standards and other regulatory systems is essential. Workable knowledge of correct coding procedures, InterQual criteria, Milliman Care Guidelines( MCG), Perspective Payment System and medical terminology is necessary. The individual must have a high energy level and be capable of handling pressure situations both mentally and physically.