Clinical Access Case Manager

2 weeks ago

Farmington, United States San Juan Regional Medical Center Full time

Love what you do; Love where you liveThe Clinical Access Case Manager will ensure regulatory compliance with CMS Conditions of Participation with regard to Utilization Management. Perform Utilization Review according to CMS and commercial payor guidelines. Participate in denial / appeal process.Required Behaviors:•As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization: Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability, and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.Required Qualifications:•Current RN or LPN license in the state of New Mexico•Minimum of five (5) years' experience in acute care required•Assertive and diplomatic communication skills•Self-motivated and accountable•Team OrientedPreferred Qualifications:•Bachelor's Degree (BSN)•Case Management experience •Accredited Case Manager CertificationDuties and Responsibilities:•Management of ports of entry. Perform and document clinical reviews to determine medical necessity, using InterQual, and physician determination of length of stay (LOC).•Receive and review physician orders on all patients coming into SJRMC and determines the accuracy of the patient status assigned, (i.e., inpatient, outpatient, or observation)•Perform concurrent utilization review as assigned following contractual obligations•Denial Management •Observation Management•Maintain current knowledge of and follow Medicare and Medicaid requirements•Proactively identifying, documenting, and escalating problems with over/under utilization of hospital resources•Collaborates effectively with departmental staff to achieve goals and objectives•Utilizes internal or external Physician Advisor as needed to resolve level of care discrepancies•Perform other duties as assigned•Each employee is responsible for implementing SJRMC's Service Standards into their daily work: Safety, Courtesy, Effectiveness, and StewardshipPhysical Demands and Environmental Work Conditions: Physical: •Minimum physical effort required•Intermittent sitting with freedom of movement•Frequent walking•Minimal bending, lifting, pulling, and reachingMental: •Frequent periods of concentration with attention to details •Frequent opportunity for diversification of tasks•Ability to shift tasks to adjust to patient needs in a timely manner•Work performed in modern, well-equipped environment•Interfaces with fellow employees, patients, and guests of hospital daily•Able to use various office equipment, including expertise in computer programs in performance of routine duties

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