Case Manager Full-Time

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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