Job Description
Job Description
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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