The Case Manager directs the utilization review of patient charts, treatment plans, and discharge planning pertaining to the quality of care and treatment criteria for patients in a specific department. The Case Manager 1 specializes in the review of information pertaining specifically to the assigned areas.
Relies on education, experience, professional training and judgment to accomplish responsibilities. A wide degree of creativity and latitude is expected. Works under minimal supervision.
Contributes to cost effectiveness/efficiency and demonstrates awareness of benefit system and cost benefit analysis. Demonstrates the ability to maximize financial outcomes of assigned patient load using the continuum of care philosophy. Assists in the development, monitoring, and analysis of annual financial goals of targeted population.
Understands the capabilities of outside referral sources such as home health, sub acute care and skilled nursing facilities. Understands the different types of healthcare delivery systems and the requirements for prior approval by payor for admissions, procedures, and continued stay. Meets with treatment team to provide utilization review information, discusses issues pertaining to continued stay, discharge and aftercare plans, evaluates current financial resources, and discusses whether documentation reflects the need for continued stay and at what level of care is the most appropriate.
Performs effective utilization review techniques to work with physicians, third party payors, and federal and local agencies to prevent denials of payment or days. Acts as a resource for unit personnel in the resolution of utilization/case management problems and expediently communicates identified problems to appropriate personnel in an effort to enhance departmental operating efficiency. Demonstrates ability to access and utilize community resources.
Is knowledgeable of the ADA and other federal legislation affecting individuals with disabilities. Knows how to establish a client support system. Education Associate#s Degree Experience Three years in general or specialty nursing practice Certification/Registration Current Louisiana RN license and unrestricted2126
Our Lady Of The Lake Regional Medical Center