Case Manager - Inland - Utilization Management

Responsibilities

Job Summary

The Case Manager oversees the process of care delivered to patients, works collaboratively, and provides leadership to the healthcare team, and is committed to organization goals. Case Manager examines records for medical treatments and interventions to avoid payment denial resulting in optimization in reimbursement by assessing appropriateness of treatments, effectiveness, timing, and setting. This includes observation level of care vs inpatient level of care based on medical necessity.

This role also includes patient assessment for discharge planning as well as appropriateness of level of care based on medical necessity. Case Manager is integral in minimizing and assisting with barriers to discharge. Coordinates/facilitates patient care progression throughout the continuum of care.

Assures the plan of care and services provided are patient focused, high quality, efficient and cost effective. Meets directly with patient/family to assess needs and develop an individualized continuing care plan in collaboration with the physician. Monitors length of stay and ancillary resource use on an ongoing basis and takes actions to achieve continuous improvement in both areas.

Communicates information to the Utilization Management or Case Management team to aid in appropriate level of care determination and reimbursement by third party payors as well as working closely with Physician Advisory team on concurrent denials to ensure most appropriate level of care prior to billing. Monitors patient flow through multidisciplinary rounds and aids in implementation of processes for improvement to decrease delays. Serves as patient advocate to ED population by identifying needs, coordinating services and resources for the management of complex patients to facilitate quality care and cost efficient outcomes.

Ensures that all elements critical to the plan of care have been communicated to the patient/family as well as members of the healthcare team. Ability to cover various populations across the organization, including the Emergency Department. Performs all other duties as requested by Case Manager Supervisor and/or Director.

Qualifications

1-2 years of recent acute care hospital experience required. Data entry/computer experience required.

Requirements

Licenses and Certifications

Registered Nurse