Saint Francis Hospital is seeking an experienced RN Care Manager to join our team!
This person will coordinate and manages all aspects of patient care from admission to discharge in collaboration with a multidisciplinary team. Serves as a resource for all members of the health care team and facilitates patient care to ensure appropriate length of stay and quality of care. Complies with the care management model that incorporates utilization, clinical care, discharge and outcomes management. Promotes and communicates plan of care with patient, family, physician and team. Serves as a patient advocate as well as an advocate for good stewardship for Saint Francis resources. Accountable to apply the nursing and clinical knowledge, skills and problem solving techniques to the case management process. Documents the provision of care management services accurately, concisely and in a timely manner in the patient record.
Reviews new admissions for medical necessity within one (1) business day of arrival using appropriate utilization criteria (InterQual) and CMS Final Rule 1599-F (2 Midnight Rule) to provide decision support for physicians in determining appropriateness of admissions and needed level of care
Assigns correct levels of care (Outpatient/ Observation vs. Inpatient Admission) with attention to the issues presented by readmissions, and avoidance of denials and appeals.
Refers cases that do not meet InterQual Criteria and/or CMS Criteria to Physician Advisor and/or designee.
Provide feedback to attending physician in order to assign the appropriate level of care(status) and issue Code 44 (Medicare).
Accurately updates clinical data and monitors intensity of service and severity of illness in a timely manner
Accurately and completely tracks indicators, variances, delays, profiles and denials
Accurately enters data into the MIDAS+ system in a timely manner
Contacts payers in a timely manner Advocates for continued authorization of hospitalization including referral of concurrent commercial denials to Physician Advisor or attending physician for peer-to peer appeal
Completes all weekend retrospective review cases by 2nd business day in week
Refers problematic cases to department manager
Refers insurance verification issues to Patient Access
Addresses documentation issues with physicians and staff.
Collaborates with physicians regarding levels of care.
Works with nursing, physicians and ancillary departments toward efficient utilization of resources.
Refers to social work for complex discharge planning.
Works closely with physicians and healthcare team to insure the patient an appropriate plan of treatment and a safe transition into the home.
Complies with all JCAHO, state, Medicare and all other appropriate agency guidelines.
Confers with physicians for orders. Uses criteria for acceptance of the patient for home health services as guidelines in determining whether the services for the patient needs may be safely and appropriately delivered in the home.
Educates and serves as a resource person to referred patients, family members, and/or significant others regarding home care.
Assists Social Services with identifying appropriate patients for Home Health Services.
Develops and maintains good working relationships with home health agencies and medical equipment companies.
Follows up professionally and appropriately when there is a problem with service provided by an agency.
Verifies insurance and obtains initial service authorization as indicated
Incorporates cultural, age-appropriate, family and environmental data into assessment and teaching.
Attends and actively participates in team conferences on nursing units.
Maintains competencies as directed by department manager.
Registered Nurse with minimum of 1 year experience as a RN Case Manager in the Acute Care setting with emphasis on Utilization Review;
Will consider RN with minimum 5 years critical care, ED, or medical-surgical experience;
Delaware Licensed or eligible; BSN preferred;
Willingness to obtain case management certification is required within one year of hire.
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