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Case Manager - Utilization Review

Not provided

$22 - $34

10 months ago

Job Description

Job Summary
Case Managers are financial managers, problem solvers, facilitators, counselors, planning consultants, educators, and advocates. The RN Case Manager promotes a collaborative process that requires assessing, developing, implementing, coordinating, monitoring, and evaluating the services required to meet an individual's health needs. She/He is responsible and accountable for coordinating the care of clients across a continuum of care, facilitating the achievement of quality, clinical and cost outcomes, and coordinating services and resources needed by the client. Demonstrates knowledge of developmental needs of patient population specific to that department. (Patient population is defined in each department's Scope of Practice.)

Qualifications
Education:  BSN or other Bachelor's in other health-related field required. Graduate from an accredited school of nursing preferred with current registration in Indiana required. CPR Provider C required within 30 days of hire. 

Training:
Require four to six weeks orientation with close supervision for six months to one year.   Experience:
Three to five years experience in acute care/critical care nursing. Independent critical thinking skills.   Job Knowledge, Skills and Abilities:
Excellent communication and organizational skills. Thorough knowledge of Hospital inpatient, observation, and discharge criteria. Familiar with organizational, policies, and procedures of hospital as they relate to Patient Services. Must have the ability to function as an individual as well as be an active member of the interdisciplinary team. Completion of basic skills checklist within 60 days. Verification of competency in basic job knowledge, skills, and ability as specified per individual department. Provides education for the patient addressing the educational needs that have been identified.

Performance Requirements
Responsibility for:
Coordinates with the multidisciplinary team to facilitate progress with the plan of care. Collaborates with the attending physician regarding patient progress and outcomes. Facilitates interdisciplinary rounds for assigned patients. Anticipates and identifies variances related to patients individual needs. Coordinates with Social Work timely and comprehensive discharge planning. Reviews and manages appropriate resource consumption. Facilitates effective communication between the health care team, patients and family members. Follows through to assure patient issues are appropriately resolved in a timely manner. Collaborates with third party payers to insure that admission criteria is met, and to certify acute care and/or post-hospital services. Guides physicians and staff with regard to admission status (inpatient, outpatient, observation) and process. Assists in the collection of data from patient charts as needed.   Physical Demands:
Walks, sits and stands intermittently. Must have auditory, visual and verbal skills to review written documents and communicate with nursing staff, Medical Staff and insurance companies via telephone. Works in office areas and departments which are well-lighted, heated and ventilated. May come in contact with hazardous health conditions; however, if proper procedure is followed no harm should come to employee.   Special Demands:
Willingness to work with realization that errors may have serious consequences for patients, physicians and facility. Nurses are encouraged to be actively involved in the community as leaders in health and wellness promotion and injury and disease prevention. Competency, tact, and patience are necessary when communicating with patients, families, physicians, and other personnel. Develop and implement techniques and/or procedures to meet the needs of physicians, patients and other personnel. Reflects the mission, philosophy, core values, and customer service plan of Memorial Hospital and Health Care Center in action and attitude. Nursing practice reflects the American Nurses Association Code of Ethics.
Experience:
Three to five years experience in acute care/critical care nursing required and independent critical thinking skills.
Job Knowledge, Skills and Abilities:
Excellent communication and organizational skills. Thorough knowledge of Hospital inpatient, observation, and discharge criteria, as well as disease management education tools, community resources, techniques to prevent readmissions, etc. Familiar with organizational, policies, and procedures of hospital as they relate to Patient Services. Must have the ability to function as an individual as well as be an active member of the interdisciplinary team.
Utilization Review
* Performs timely clinical reviews to ensure medical necessity (initial, continued stay and retro)
* Reviews and manages appropriate resource consumption
* Collaborates with third party payers to ensure that admission criteria is met, and to certify acute care and/or post-hospital services
* Guides physicians and healthcare team with regard to admission status (inpatient, outpatient, observation) and process
* Assists in the collection of data from patient charts as needed
* Anticipate/identifies patient variance days to reduce avoidable days
* Performs Observation chart audits  

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