Requirements:

Must have 2 years of acute RN Case Management experience in a hospital setting (200-300 bed). Must have utilization review and discharge planning experience. Schedule is M- F rotating weekends 8:00 AM-4:30 PM at the Zion Medical Center

Description:

This position integrates national standards for case management scope of services including: Utilization Management supporting medical necessity and denial prevention, Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care, Compliance with state and federal regulatory requirements, TJC accreditation standards and policy Education provided to physicians, patients, families and caregivers, and other duties assigned. Essential Responsibilities: The individual's responsibilities include the following activities:

a) accurate medical necessity screening and submission for Physician Advisor review

b) care coordination,

c) implementation of the transition plan based on RN Case Manager and/or Social Worker (SW) assessment(s),

d) communication with interdisciplinary team during patient care conferences,

e) management of concurrent disputes,

f ) communication with patients and families regarding the plan of care established by RN, SW and Physician,

g) collaboration with physicians, office staff and ancillary departments,

h) clear, complete and concise documentation in electronic system,

i) maintenance of accurate patient demographic and insurance information,

j) identification and documentation of potentially avoidable days,

k) identification and reporting of over and underutilization,

l) and other duties as assigned

Utilization Management: Assures the patient is in the appropriate status and level of care based on Medical Necessity process and submits for Secondary Physician review per Kaiser policy. Ensures timely communication of clinical data to various payers to support admission, level of care, length of stay and authorization for post-acute services. Advocates for the patient and hospital with payers to secure appropriate payment for services rendered. Completion of clinical reviews. Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes. Identifies and documents Avoidable Days using the data to address opportunities for improvement. Prevents denials and disputes by communicating with payers and documenting relevant information. Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) supported by evidence-based practice, internal and external requirements. Identifying appropriate level of care needs. Assisting with patient transition to the appropriate level of care. Order clarification admission status and patient classification.

Skills:

case management, acute care, registered nurse, data entry, utilization management, Care management, Health care, Medical, Insurance verification, Customer service, Rn license

Top Skills Details:

case management, acute care, registered nurse, data entry, utilization management

Additional Skills & Qualifications:

Registered Nurse - RN NEED ACUTE EXPERIENCE

Experience Level:

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