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Under the general supervision of the Case Management Manager acts as a patient advocate/Case Manager to SSH&EC clients. An autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost efficient patient outcomes. Looks for opportunities to reduce cost while assuring the highest quality of care is maintained. Applies review criteria to determine medical necessity for admission and continued stay. Provides clinically-based case management, discharge planning and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care. Works collaboratively with interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. The Case Manager is on-site and available seven (7) days a week as well as holidays and, therefore, is required to work a weekend rotation and also an occasional holiday.
Job Responsibility:
Acts as a patient advocate/Case Manager
Coordinates, negotiates, procures services and resources for, and manages the care of complex patients
Applies review criteria to determine medical necessity for admission and continued stay
Provides clinically-based case management, discharge planning and care coordination
Works collaboratively with interdisciplinary staff
Participates in quality improvement and evaluation processes
Works a weekend rotation and occasional holiday
Review medical records for appropriate utilization
Assist physician in determining medical necessity
Identify cases failing criteria
Contact physicians regarding documentation
Notify physician/patient of insurance termination
Reinstates insurance coverage
Provide clinical data to payers
Assist with determination of observation status
Consult on patient status
Take telephone orders for status changes
Participate in case finding and pre-admission screening
Identify transition planning problems
Assess patient acute level of care needs
Implement safe discharge plans
Facilitate patient care rounds
Conduct conferences
Coordinate necessary resources
Update interdisciplinary patient White Board
Issue Medicare Important Message (IM)
Ensure patient receives choice of follow-up care facilities
3-5 years acute care hospital experience preferred
Critical Care or Emergency Department experience highly desirable
RN - Registered Nurse license
ACM - Accredited Case Manager or CCM - Certified Case Manager within two years of hire
Demonstrated skills in: negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking, time management and ability to multitask in high stress environment
Knowledge of: healthcare financing, community and organizational resources, patient care processes, and data analysis
Knowledge of utilization management as it relates to third party payers
Knowledge of post-acute care community resources
Experience with Managed Care preferred
Excellent verbal and written communication skills required
Demonstrates flexibility via an ability to adapt to changing priorities and regulations