Description

JOB SUMMARY

The RN Case Management Specialist is responsible for providing administrative support to the Director of Case Management. Duties include but not limited to assigning various tasks, assisting with overseeing day to day operations and the denials process. This person must be able to collect, organize and present pertinent clinical information. Proficient verbal and written skills are required. This coordinator will be able to assist with education to hospital staff and physicians on the subject of federal and commercial payer regulations to prevent medical necessity denials. This position reports to the Director of Case Management.

Requirements

JOB REQUIREMENTS

Minimum Education

Graduate of an accredited school of professional nursing.

Licensure as Registered Nurse in the state of KY.

Bachelor’s degree in a health related field required.

Current certification BLS certification.

Minimum Work Experience

Minimum of 5 years health care experience. Experience with utilization management, insurance

authorizations, precertification & medical necessity criteria required. Prior case management experience

preferred

Required Licenses

[Kentucky, United States] Registered Nurses

Current Kentucky RN license.

Required Skills

The ability to plan, schedule and organize departmental activities. Excellent written and oral communication

skills required. Capable of maintaining accurate record keeping. Must be able to perform duties and maintain

personal conduct, attitude and appearance that conform to policies and procedures of the department and

facility. Skills in establishing and maintaining effective and professional relationships with TJSCH employees

and public will be essential.

FUNCTIONAL DEMANDS

Physical Requirements

Sitting - 16 – 31%

Walking - 1-32%

Standing - 1-32%

Bending/Squatting - 16-31%

Climbing/Kneeling - 16-31%

Twisting - 16-32%

Visual and Hearing Requirements

Must be able to see with corrective eye wear if needed.

Must be able to hear clearly with assistance if needed.

Must be able to distinguish colors.

Physical/Environmental Requirements

Lifting - 0-50 lbs, 50 or more with assistance

Carrying - 0-50 lbs, 50 or more with assistance

Pulling - Up to 200 lbs

Pushing - Up to 200 lbs

OSHA Category

Minimal potential for direct exposure.

LEADERSHIP CAPABILITIES

Mission, Service, and Values

Supports the hospital Mission, Service and Values.

ESSENTIAL FUNCTIONS

• Certification from CCM is recommended.
• Assists in ensuring effective communication with all members of the Case Management team
• Assists Director of Case Management with monthly reporting
• Able to apply clinical criteria to determine appropriate level of care and medical necessity.
• Must be able to write concise, factual letters to support appeal process.
• Able to work independently and efficiently with excellent time management skills.
• Work requires substantial interpersonal skills to develop and maintain cooperative working relationships with personnel from other departments.
• Assist in maintaining Case Management services by organizing office operations and procedures, assigning and monitoring clerical functions
• Assist in coordinating any changes to policies to staff, providers, or administration
• Demonstrates leadership skills
• Contributes to an efficient, cooperative and pleasant office atmosphere.

Completes other assignment

ORGANIZATIONAL EXPECTATIONS

T.J. Pledge

I Will Show Compassion

-see all patients, family members, coworkers, physicians, and anyone else at T.J. as my customer.

-recognize that each and every interaction I have at T.J. Regional Health matters

-show kindness and compassion towards my customers at all times

-be sensitive to the personal and private needs of every customer

I Will Cooperate With Others

-maintain zero tolerance for abusive behavior

-listen and be willing to accept fault when I make a mistake

-never underestimate the power of an apology

-refrain from blame and judgment

-bring a sense of calm to stressful situations

I Will Collaborate With Others

-value myself and every coworker as an equal part of one GREAT team working together

-treat others in a way that I would like to be treated

-participate only in conversations that are courteous, respectful, and reflect positively on my teammates and T.J. Regional Health

-foster a calm and pleasant atmosphere, and refrain from gossip, rumors, and insults

-speak honestly, seek truth, and act with integrity towards my teammates

-value the uniqueness and expertise that each team member contributes to the whole

-meet the need of the moment, regardless of whether or not it is considered part of my job

I Will Communicate

-smile - at everyone

-always introduce myself, my role, and my purpose use body language, eye contact, and tone of voice that shows respect in every interaction

-follow the 10/5 rule: always acknowledging people at 10 feet away with a smile and always greeting people at 5 feet away

-escort any customer in need (visitors, patients) to their destination

I Will Adapt To Change

-be a part of the solution when I am presented with a challenge

-embrace change and set the example for those around me

-accept openly when there are changes that T.J. Regional and/or I have no control over

-manage the expectations of others by explaining duration and next steps as often as needed

I Will Be A Champion

-serve with passion

-view myself as an owner of T.J. Regional Health and act accordingly

-take responsibility for the physical appearance of T.J. Regional Health, including my work area

-go out of my way to daily thank and compliment my customers and coworkers

-dare to make a difference and be exceptional

-constantly try to improve myself and T.J. Regional Health

-speak positively about T.J. Regional, while at work and in public places outside of work