Spartanburg Regional Medical Center Spartanburg , SC 29306
Posted 2 months ago
Position Summary Under the supervision of the Manager, the experienced#Part-Time
Graduate of an accredited school of nursing
, Bachelor#s Degree (other than nursing) with an ADN or an accredited school of Social Work (MSW) Experience
1-3 years Case Management experience (Care Coordination, Transitions of Care or Utilization Management) or#3-5 years healthcare experience License/Registration/Certifications
Current R
.N. licensure in the state of SC or Current Social Work licensure in the state of SC Preferred Requirements Preferred Education
BSN
, MSW Preferred Experience
3-5 years case management Preferred License/Registration/Certifications
RN, LMSW Core Job Responsibilities Complies with established policies and procedures Complies with regulatory requirements of utilization review and discharge planning Responsible for assessment and reassessment of patients# physical, social, emotional and financial needs. Develops a comprehensive patient centered discharge plan, incorporating the patient goal into the discharge plan Communicates with the patient/family/caregiver and interdisciplinary patient care team to facilitate patient care, development of a comprehensive patient centered discharge plan and utilization review functions Negotiates timely decisions to expedite the discharge plan and ensure seamless transitions across the continuum of care Documents clearly and concisely all contacts and information of the patient#s case management#process in the medical record Responsible for the core functions of the Utilization Management Plan Performs initial and subsequent utilization reviews utilizing criteria. With utilization review, obtains certification on admissions and continued certification by providing clinical information to the payer or to review companies designated by the patient#s payer. Monitor and secures final certification up to and after patient discharge until resolved. Assists with management of incoming faxed communications With utilization review, assists with initial denial, peer to peer information, status determination and/or appeal process and communicates necessary information to the physician advisor, CM manager, denials team manager and/or QIO as required Uses communication tools to ensure that information is collected, reviewed, escalated if needed and disseminated appropriately for all commercial, managed care and government plans. Communicates updated insurance information to the centralized referral center if insurance information provided is not accurate Performs timely data entry of information when results are received including covered, denied and avoidable days. Complies with delivery of regulatory notices
Position Summary
Under the supervision of the Manager, the experienced Part-Time
Minimum Requirements
Education
Experience
License/Registration/Certifications
Preferred Requirements
Preferred Education
Preferred Experience
Preferred License/Registration/Certifications
Core Job Responsibilities
Complies with established policies and procedures
Complies with regulatory requirements of utilization review and discharge planning
Responsible for assessment and reassessment of patients' physical, social, emotional and financial needs.
Develops a comprehensive patient centered discharge plan, incorporating the patient goal into the discharge plan
Communicates with the patient/family/caregiver and interdisciplinary patient care team to facilitate patient care, development of a comprehensive patient centered discharge plan and utilization review functions
Negotiates timely decisions to expedite the discharge plan and ensure seamless transitions across the continuum of care
Documents clearly and concisely all contacts and information of the patient's case management process in the medical record
Responsible for the core functions of the Utilization Management Plan
Performs initial and subsequent utilization reviews utilizing criteria.
With utilization review, obtains certification on admissions and continued certification by providing clinical information to the payer or to review companies designated by the patient's payer. Monitor and secures final certification up to and after patient discharge until resolved. Assists with management of incoming faxed communications
With utilization review, assists with initial denial, peer to peer information, status determination and/or appeal process and communicates necessary information to the physician advisor, CM manager, denials team manager and/or QIO as required
Uses communication tools to ensure that information is collected, reviewed, escalated if needed and disseminated appropriately for all commercial, managed care and government plans.
Communicates updated insurance information to the centralized referral center if insurance information provided is not accurate
Performs timely data entry of information when results are received including covered, denied and avoidable days.
Complies with delivery of regulatory notices
Plans effectively in order to meet patient needs, manage length of stay and promote efficient utilization of resources.
Provides cost-effective services through resource management and facilitating throughput while maintaining quality care and meeting customer service needs by collaborating with healthcare providers to coordinate care delivery
Provides patient/family/caregiver with quality data-based information on post-acute providers to facilitate referrals to meet the care transition needs of the patient
Utilizes a secure electronic platform to communicate with post-acute providers and payers
Completes required education and ongoing competencies as assigned
Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations
Other duties as assigned
Spartanburg Regional Medical Center