At Our Lady of Lourdes we offer you much more than just a job in the healthcare industry. We offer career opportunities for people who have a calling to share their gifts and talents as part of our healing ministry. As a Catholic hospital, we are here to create a spirit of healing - and we invite you to join our team today if you would like to be part of that spirit. In addition to competitive salaries and generous benefits, we offer you something special - the chance to do God's work by helping to serve people in need throughout our community, every day.

Job Summary: The Case Manager 1 directs the utilization review of patient charts, treatment plans, and discharge planning pertaining to the quality of care and treatment criteria for patients in a specific department. The Case Manager 1 specializes in the review of information pertaining specifically to the assigned areas. Relies on education, experience, professional training and judgment to accomplish responsibilities. A wide degree of creativity and latitude is expected. Works under minimal supervision.

Experience, Education, Training, Special Skills, and Licensure:

• 3 years clinical experience
• Graduate from Accredited RN Program
• Current Louisiana State License as RN

Job Function:

1. Case Management
   1. Demonstrates the ability to maximize financial outcomes of assigned patient load using the continuum of care philosophy. Assists in the development, monitoring and analysis of annual financial goals of targeted population
   2. Performs effective utilization review techniques to work with physicians, third party payors and federal and local agencies to prevent denials of payment and days
   3. Acts as a resource for unit personnel in the resolution of utilization/case management problems and expediently communicates identified problems to appropriate personnel in an effort to enhance departmental operating efficiency
   4. Evaluates the quality of necessary medical services, utilizes criteria to determine medical necessity of admissions and interacts with physicians to facilitate patient assignment to appropriate alternative of care.
   5. Understands the capabilities of outside referral sources such as home health, sub acute care and skilled nursing facilities. Understands the different types of healthcare delivery systems and the requirements for prior approval by payor for admissions, procedures and continued stay.
   6. Meets with treatment team to provide utilization review information, discusses issues pertaining to continued stay, discharge and aftercare plans, evaluates current financial resources, and discusses whether documentation reflects the need for continued stay and at what level of care is most appropriate
   7. Provides appropriate and timely information to third party payors to facilitate financial outcomes and ensures patients are receiving appropriate level of care; includes coordinating denials/appeals
   8. Collaborates with all members of the health care team to ensure reimbursement optimization, appropriate discharge planning and cost effective quality care. Plays a key role in the discharge planning process assessing patients needs for referrals and/or alternate levels of care. Appropriately tracks and report avoidable days
   9. Demonstrates ability to access and utilize community resources. Knows how to establish a client support system
   10. Demonstrates competence in coordination and service delivery. Understands methods for assessing an individuals level of physical/mental impairment. Assesses patient clinical information and in collaboration with the healthcare team develops treatment/discharge plans
   11. Strives to promote the quality and efficiency of his/her own performance by remaining current with the latest trends in field
   12. Promotes concurrent DRG/documentation management via feedback and education to physicians regarding appropriated documentation that reflects patient acuity and resource utilization
2. Other Duties as Assigned
   1. Good interpersonal/human relations skills
   2. Good oral and written communication skills.
   3. Good problem solving and critical thinking skills
   4. Good time management/prioritization skills.
   5. Performs other duties as assigned or requested.
   6. Consistently performs 12 organizational Service Standards focused on Values, Service and Quality.