Case Manager, Rn Prn Days

2 weeks ago

Sunnyvale, United States Baylor Scott & White Medical Center - Sunnyvale Full time

**JOB SUMMARY**

Assesses, plans, implements and evaluates the needs of patients for discharge planning and utilization review. This includes those who may have Medicare, Medicaid, HMO or private insurance to cover their stay at various units. Discharge planning is coordinated with physicians, nursing, patient and significant others who have an ongoing caring relationship with the patient. Utilization review procedures include those stated for discharge planning in addition to knowledge of criteria for Medicare, Medicaid coverage and that of HMO or private insurers.

**DUTIES AND RESPONSIBILITIES**
- Essential Job Duties _
- Responsible for performing assessments on Medicare, Medicaid, Private Pay, Commercial insured and high-risk patients to determine discharge planning needs, always documents assessments. (Interqual criteria review proficiency)
- Able to communicate with physician regarding Medical necessity of the patient. Assists the physician to facilitate optimal documentation to support level of care.
- Is knowledgeable of criteria for Medicare, Medicaid, Commercial and private insurance coverage.
- Communicates daily with admissions personnel regarding admissions and discharges to various units, when applicable.
- Treats patients and families with respect and dignity.
- Interacts professionally with patient/family and involves patient/family in the formation of the plan of care if necessary.
- Is knowledgeable of patient’s financial status, diagnosis and discharge needs.
- Acts on performance improvement issues identified during CQI meetings.
- Collaboration with insurance Case Manager to assure clinical information submitted/received.
- Maintains and respects confidentiality of patient/physician/personnel information
- Collaborates with the Business Office Manager, insurance verification, Clinical Documentation Specialist and Authorization Coordinator to facilitate obtaining authorizations for appropriate level of care.
- Actively participates in Utilization Management Committee, CQI, varying team meetings and other meetings as appropriate.
- Demonstrates an ability to be flexible, organized and function under stressful situations.
- Maintains a good working relationship both within the department and with other departments.
- Consults other departments as appropriate to collaborate on patient care and performance improvement activities.
- Documentation meets current standards and policies.

**PROFESSIONAL REQUIREMENTS**
- Adheres to dress code; appearance is neat and clean.
- Completes annual educational requirements.
- Maintains regulatory requirements, including all state, federal and JCAHO regulations related to the Imaging Services Department and, as appropriate, to the facility.
- Maintains and ensures patient confidentiality at all times.
- Reports to work on time and as scheduled.
- Wears identification while on duty.
- Attends annual review and performs departmental in-services.
- Works at maintaining, a good rapport and a cooperative working relationship with physicians, departments and staff.
- Represents the organization in a positive and professional manner.
- Attends committee, CQI and management meetings, as appropriate.
- Resolves personnel concerns at the departmental level, utilizing the grievance process as required.
- Ensures compliance with policies and procedures regarding department operations, fire, and safety and infection control.
- Effectively and consistently communicates administrative directives to personnel and encourages interactive departmental meetings and discussions.
- Complies with all organizational policies regarding ethical business practices.
- Attends at least 8 staff meetings annually, is responsible for information presented at monthly staff meetings that he/she is unable to attend.

**REGULATORY REQUIREMENTS**
- Current Registered Nurse licensure in State of Texas.
- Medical Surgical nursing within past 3 -5 years
- Is a motivated, independent individual who can organize workload so that all functions are completed appropriately
- Working knowledge of criteria for Medicare, Medicaid, HMO and private insurance coverage.
- Annual Interqual review/proficiency
- Experience in providing patient care.

**LANGUAGE SKILLS**
- Ability to read and communicate effectively in English.
- Additional languages preferred.

**SKILLS**
- Basic computer knowledge

2403002707

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