Case Manager RN

Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health care facility to comply with government and insurance company reimbursement policies by performing the duties required through personally or through subordinate supervisors.

Reports to: CNO

Essential Functions

Evaluate each Inpatient and Outpatient case within 24 hours of admin to assure appropriate physician order and other documentation to support the appropriate level of care for the patient based upon criteria set for my CMS and by Commercial Insurance Companies.

Assure appropriate insurance authorizations as needed.

Work with Medical Staff to educate and facilitate required documentation to support the appropriate level of care for each patient, including participation in the Clinical Documentation Program

Facilitate Discharge Planning through team collaboration for each patient that includes services required post discharge such as Home Health, Outpatient Therapies or skilled nursing care including Swing Beds and education regarding that care.

Documents actions taken to evaluate and facilitate the Case Mgt review and discharge planning.

Participate in statistical tracking and reporting of the Utilization Management metrics.

Facilitates appeals of denials as needed, including analysis and corrective actions for denials due to those processes within the scope of the Case Management functions.

Organizational Expectations

Actively participates in Foundation Safety Behavior Tools and Tactics such as Briefs, Debriefs, Huddles, Learning Board Activities, Executive Patient Safety Rounds and reporting of unanticipated and unintended patient events regardless of whether there is a harm.

Provide effective mentoring

Be loyal to the absent

Always manage up

Consistent use of AIDET & 5 P's

Uphold the facilities Standards of Performance

Job Requirements

Minimum Education

Current RN license in the State of Tennessee

Required Skills

High level interpersonal skills to handle sensitive and confidential information. Position required ability to work with patients and families to achieve appropriate continuum care for the patient.

Required Skills

Certifications:

Basic Life Support (BLS) within 90 days of hire date.

Advanced Cardiovascular Life Support (ACLS) within 90 days of hire date.

Pediatric Advanced Life Support (PALS) within 90 days of hire date.

Neonatal Resuscitation Provider (NRP) within 90 days of hire date.

Perioperative Nurse (CNOR) within 90 days of hire date.

Required Skills

Licenses: Current Tennessee RN license.

Required Skills

Basic computer skills.

Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran