Job Summary:

Seeking an experienced case manager with +5 years of experience in an acute hospital setting.

Qualifications:

• Experience
  • 5+ years of experience in managed care
  • Substantial clinical experience
• Education
  • Bachelor's degree (required)
  • Masters (preferred)
• Licensing
  • Foreign Medical Graduate or Registered Nurse (preferred)
  • CCM (Certified Case Manager) (preferred)
  • ACM (Accredited Case Manager) (preferred)
• Bilingual (English/Spanish) (preferred)

Responsibilities:

• Performs and documents patient assessment within 24 hours of admission
• Checks prior authorizations initiative by admitting
• Knowledge navigating and using payer portals
• Performs concurrent reviews
  • Contacting all HMO’s on a daily basis and provides clinical information to obtain insurance authorization for the patient’s admission and continued stay
• Indicates the appropriate level of care and utilization of services needed
• Establishes criteria for medically necessary services
  • Knowledgeable of Milliman Care and Interqual Guidelines
• Develops a plan of care for patients from admission to discharge. 
• Promotes the most efficient and cost-effective use of services
• Curtails the performance of inappropriate and/or duplicate services
• Encourages standardization of medical practice patterns
• Enhances the quality of healthcare
• Performs concurrent reviews for patients to ensure that extended stays are medically justified and are documented in patient's medical records.
• Calculates and manages the lengths of stay and continued-stay days for patients.
• Evaluating the patient’s condition and readiness for discharge planning
• Develops discharge plans
• Communicate and assist the physicians in the planning and coordination of patients discharge planning
• Management of transfer procedures
• Management of the guardianship process
• Able to discuss and educate patient/family regarding discharge planning and resources available after discharge. Clearly specifies all the information discussed with the patient and/or family regarding the patient’s discharge plan.
• Participates in PI programs through the identification of opportunities for improvement, data collection, evaluation of findings, improving the process, applying knowledge and incorporates into practice
• Scheduling Peer-to-Peer reviews with payors
• Proactively identifying and resolving issues that could lead to denials

Skills:

• Familiarity with Medhost electronic medical records
• Extensive medical knowledge
• Self-driven (work and education)
• Keeps knowledge up to date by reading literature and participating in outside continued education meetings, training, and conferences
• Working knowledge of regulatory agencies
• Excellent human relations and communication skills (verbal and written) to maintain good rapport and effective working relationships with medical staff, nursing staff, and other ancillary department staff throughout the hospital
• Excellent organizational skills and attention to detail
• Ability to convey care plan to physicians and the medical team
• Proficient with Microsoft Office Suite or related software.
• Integrity

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