Case Manager

2 days ago

Newark, United States ChristianaCare Full time

Case Manager (RN) - Utilization Management - Weekend Incentive Program (WIP)

Weekend Shift: Saturday & Sunday (Hours: 7pm-7am)

Newark, DE

Christiana Care Hospital currently recruiting a Registered Nurse (RN) for our Weekend Incentive Program (WIP) with experience in Utilization Management in an Acute Care Hospital Setting. The Utilization Management Nurse will work with ED providers to review medical necessity and collaborate for discharge planning, as appropriate.

The Utilization Management Nurse will be responsible for ensuring the delivery of efficient and effective health care while evaluating the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provision of the applicable health benefits plan.

As part of our Weekend Incentive Program (WIP) you will commit to work 3 out of 4 weekends per a four-week schedule for 12-hour shift on Saturdays, and Sundays from 7p - 7a.

Weekend Incentive Program Include: Special rate of pay and full benefits, except for Paid Time Off (PTO).

Scope, Purpose, And Frequency of Contacts:

Works collaboratively with the Utilization Management team, Denial Manager, Physician Advisor, Physician staff, Nursing staff, Case Management, Finance, Clerical Support staff and payer liaisons.

UTILIZATION MANAGEMENT:

  • Performs admission and concurrent review to identify medical necessity, level of care and appropriateness of setting using established criteria and clinical guidelines within 24 hours of admission.
  • Reviews the admission assessment, collaborates with primary nurse and other health care providers to ensure a multidisciplinary plan-of-care is in place to meet identified patient care needs and desired outcomes.
  • Manages observation level of care and works with the attending physician and/or clinical provider caring for the patient to ensure observation status does not exceed 48 hours
  • Identifies system issues that serve as barriers to care. Participates in development and implementation of strategies to remove barriers and facilitate performance improvement measures.
  • Monitors efficiencies in scheduling diagnostic procedures and coordination of treatments to facilitate achievement of effective clinical, fiscal, quality, and patient satisfaction goals.
  • Reports information generated from the utilization management referral process for LOS data and physician profile database.
  • Collaborates with the unit medical director and/or physician advisor to facilitate achievement of clinical, quality, financial and patient satisfaction goals.
  • Notifies physician when patient does not meet criteria for acute care hospitalization, pursues documentation to justify continued stay within 24 hours.
  • Collaborates with the Physician Advisor to facilitate achievement of clinical, quality, financial and patient satisfaction goals.
  • Presents "Letters of Non-Coverage (LON) to patients and/or families when acute stay is no longer necessary (Third Party and/or Medicare).
  • Communicates and secures continued stay authorization with Managed Care Organizations.
  • Tracks all carve-outs and submits reason codes for data entry.
  • Serves as a resource to nursing and ancillary staff, providing education on utilization review processes as needed.
  • Trends potential barriers to patient advancement through the system, intervenes assertively and appropriately when necessary.
  • Provides On-call support for the Transfer Center to evaluate medical necessity and appropriateness when a request is obtained from an outside facility for patient transfer to Christiana Care.
  • Identifies need for patient to be evaluated by other members of the health care team and takes appropriate action to facilitate.

PERFORMANCE IMPROVEMENT:

  • Monitors compliance with National Patient Safety Goals within assigned unit.
  • Assists with data collection and implementation of action plans for CMS, JCAHO, AHA Quality Initiatives as well as CCHS defined measures. Collaborates with performance improvement to identify opportunities, recommend selections, and support PI initiatives to improve outcomes on assigned units.

About Us

Christiana Care is one of the country's most dynamic healthcare organizations, centered on improving health outcomes, making high-quality care more accessible, and lowering healthcare costs. Christiana Care includes an extensive network of outpatient services, home health care, urgent care centers, three hospitals (1,336 beds), a free-standing emergency department, a Level I trauma center, a Level III neonatal intensive care unit, a comprehensive stroke center and regional centers of excellence in heart and vascular care, cancer care and women's health.

Christiana Care Offers

  • Medical, Dental, Vision, Life Insurance, Tuition assistance, etc.
  • Two retirement planning offerings, including 403(b) with company contributions.
  • Generous paid time off with annual rollover and opportunities to cash out.
  • 12-week paid parental leave
  • Incredible Work/Life benefits including annual membership to access to backup care services for dependents through retirement planning services, financial coaching, fitness and wellness reimbursement, and great discounts through several vendors for hotels, rental cars, theme parks, shows, sporting events, movie tickets and much more

EDUCATIONAL REQUIREMENTS:

  • Active DE RN licensure or compact state RN licensure.
  • Bachelor's degree in nursing
  • Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting.
  • Clinical Documentation, Performance Improvement, Case Management or Utilization Management experience desirable.
  • Completes a minimum of 8 continuing education credits (CEU'S) per year in Utilization and/or Case Management.
  • Actively participates in department operational planning work groups.

PHYSICAL DEMANDS:

Ability to ambulate within the hospital setting (walking, stairs, etc.). Occasional sitting, standing, and lifting loads of 5-10 pounds. Ability to utilize computer equipment/programs. Ability to sit or stand at a computer workstation and proficiently utilize computer equipment/programs for long periods of time.

WORKING CONDITIONS:

Occasional exposure to Office materials (i.e., White Out, Toner, etc.)

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