A small community 36-bed facility has a full-time Case Management position available. The Case Manager has well-developed knowledge and skills in areas of utilization management (UM), and Discharge Planning. This individual supports the Case Management program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. Discharge Planning includes assessments, MOON/IMM, and coordination with outside vendors for DME/HH/SNF/Rehab when needed.
Education: Minimum bachelor’s degree in nursing
Experience:
- Minimum five (5) years relevant clinical nursing experience
- Minimum of three (3) years acute hospital experience as a License Registered Nurse with Case Management
- Minimum of one (1) year experience with Utilization Review; MCG certification preferred.
Licenses/Certificates:
- RN in the state of Texas
- CCM/CCMC preferred
- MCG Certification preferred
General Responsibilities
- Coordinate and facilitate correct identification of patient status.
- Collaborate and set standards with RNs, CMs and appropriate hospital staff that all admitted patients have the correct admission status (inpatient, outpatient short stay, OBS) so that the appropriate claim can be made to commercial and government payers.
- Complete continued, concurrent & extended reviews utilizing MCG (Milliman Care Guidelines).
- Submit clinicals to appropriate payors & follow-up medical record request.
- Collaborate with nursing, physicians, admissions, compliance, coding and billing staff to answer clinicals questions related to medical necessity and patient status.
- Provide morning reporting utilizing Patient Care Conference template for hospital staff.
- Identify and facilitate resolution of system process problems impeding UM functions. Identify and resolve delays and obstacles as appropriate.
- Coordinate and integrate UM functions.
Job Type: Full-time
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Retirement plan
- Vision insurance
Schedule:
Experience:
- Case management: 1 year (Preferred)
Work Location: In person