Job Overview:

Promotes high quality patient care and cost effective utilization of hospital resources through concurrent and retrospective evaluation of patient care through the medical record. Performs concurrent review of Managed Care to obtain payment for services rendered. Monitors Medicare patients for appropriate utilization. Formulates discharge plans for patients for continuation of care needs. Reports to Director of Patient Management.

Qualifications:

Required:

* Prior case management experience

* Excellent verbal and written communication skills required

* Must be able to make decisions, work independently and communicate effectively with Interdisciplinary teams, patient, families, and physician staff to formulate a safe discharge plan

Preferred:

* Diverse clinical experience in both Med/Surg and Critical Care a plus

* 3 - 5 years clinical hospital experience preferred

* Case Management Certification preferred

Certifications and Licenses Required:

* Currently licensed NJ Registered nurse

Essential Functions:

* Conferences with Physician advisor and attending physician to discuss plan of care. Coordinates with ancillary departments to mobilize resources for completion of timely inpatient care.

* Independently determines level of care and communicates through Notice of Non-coverage letters when required.

* Utilizes guidelines with Managed Care. Documents appropriate guidelines used in determination. Documents information related to case for consideration when appealing. Reports level of care changes to director.

* Obtains authorization and utilizes ambulance transport when needed and informs families of Medicare guideline requirements.

* Completes concurrent and retrospective review according to departmental UR plan inlcuding Interqual, Milliman, and/or Medicare guidelines.

* Communicates with payors regarding assessments, utilization of resources, outcomes, and anticipated length of stay.

* Reviews each case for appropriateness of admission or assignment to observation status. Initiates communication and referral activity to maintain status criteria.

* Completes reviews on assigned patients daily and enters information into canopy using Interqual, Milliman, and/or Medicare guidelines.

* Monitors appropriates of test/procedures, consultation, treatment plans and resource utilization. Discuss findings and refers appropriately.

* Maintains and assures adherence to clinical paths, tools and protocols through collaboration with the interdisciplinary team to reduce LOS and resource utilization.

* Leads the Interdisciplinary rounds in collaboration of the team and plays an active role in providing for the continuum of care.

* Coordinates with ancillary departments to mobilize resources for completion of timely inpatient care.

* Facilitates patient movement to appropriate (acuity) level of care through collaboration with patient/family, interdisciplinary team, and payors.

* Coordinates and documents discharge planning needs within the department timeline including choice with regards to Medicare.

* Assists families in understanding discharge planning options and obtains authorization for services when needed.

* Proactively work with patients, families, physicians and the interdisciplinary team to prepare the patient for a safe discharge post hospitalization.

* Identifies, documents and reports variances such as risk for readmission, quality, safety and infection control issues.

* Reports and works actively to address quality of care issues such as delays and inappropriate utilization in treatment, appropriately escalating times as needed.

* Demonstrates fiscal responsibility related to patient needs, resource utilization, payor requirements and organizational goals.

* Maintains awareness of department staffing needs and demonstrates flexibility and willingness to assist coworkers in other areas as census/staffing demands.

* Work hours reflect productivity, commitment and flexibility toward needs of department and hospital goals.

* Demonstrates motivation and initiative in role performance; proactively address identified issues and resolves problems.

* Contributes to departmental/organizational project and performance improvement activities

* Participates in activities that increase professional/departmental knowledge and skills such as attendance in lectures, conferences, in-service programs and meetings.

* Monitors Epic work queues and addresses outstanding items

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Additional Information:

At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical, emotional, social, and financial health.

* Paid Time Off (PTO)

* Medical and Prescription Drug Insurance

* Dental and Vision Insurance

* Retirement Plans

* Short & Long Term Disability

* Life & Accidental Death Insurance

* Tuition Reimbursement

* Health Care/Dependent Care Flexible Spending Accounts

* Wellness Programs

* Voluntary Benefits (e.g., Pet Insurance)

* Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!

Choosing RWJBarnabas Health!

RWJBarnabas Health is the premier health care destination providing patient-centered,

high-quality academic medicine in a compassionate and equitable manner, while delivering

a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.

RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.

Equal Opportunity Employer

RWJBarnabas Health is an Equal Opportunity Employer