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RN Case Manager

2 months ago

Alma, Nebraska, United States Harlan County Health System Full time
Job Summary

The RN Case Manager - Clinical Coordinator will collaborate with the healthcare team to assess patient plans of care and expected outcomes, with a focus on discharge services. This role will analyze patient records to ensure compliance with government and insurance reimbursement policies.

Key Responsibilities
  • Ensure the implementation of screening, assessing, evaluating risks, planning, and follow-up programs for patient care coordination.
  • Function as the Case Management RN for overall care coordination across the organization.
  • Provide off-hours support for phone calls from providers and staff regarding patient care.
  • Conduct concurrent and retrospective record reviews to ensure compliance with patient classifications.
  • Obtain authorizations and pre-authorizations for inpatient, observation, and test/procedure orders to ensure hospital requirements are met.
  • Act as a hospital resource for participation with Medicare/Medicaid and Peer Review Organization to ensure feedback is provided to providers for necessary documentation.
  • Issue CMS forms as required.
  • Direct discharge planning processes with the healthcare team to support treatment adherence and medication compliance.
  • Oversee follow-up with discharged patients to ensure compliance with discharge plans and identify care issues for resolution.
  • Evaluate referred patients' appropriateness for acceptance into the SWING bed program.
  • Accept referrals for evaluation using the SWING bed Intake Form.
  • Compare medical record information to established criteria and confer with the healthcare team to determine ability to meet treatment goals and length of stay.
  • Evaluate seniors'/client's medical information to determine Medicare, Medicaid, and private insurance reimbursement issues, and act on issues as identified.
  • Provide information to seniors/client/families regarding financial concerns, including general information regarding Medicare, Medicare Part D, and application for Medicaid and other financial assistance programs.
  • Assist community members with Medicaid application processes.
Requirements
  • Current NE State License as a Registered Nurse required or ability to obtain.
  • CMGT-BC - Nursing Case Management Certification from the American Nurses Association or the ability to obtain within 3-5 years.
  • Approximately 3-5 years of progressively more responsible clinical work-related experience.
  • Professional knowledge of nursing practice, and regulations to support patient care delivery, evidence-based practice, utilization review, and case management.
  • Interpersonal skills necessary to effectively communicate with a wide variety of hospital personnel, community residents, and outside agency personnel.
  • Analytical skills necessary to develop and prepare special and recurring reports or analysis.
  • Current BLS, ACLS, PALS or ability to obtain within 2 months of hire.
  • Current TNCC or ability to obtain within 9 months of hire.
Work Environment
  • The employee will primarily work in an office setting.
  • The noise level in the work environment is usually low to moderate.
  • The employee may occasionally need to visit other areas within the facility or external locations for meetings or other work-related activities.
Physical Demands
  • The employee is regularly required to sit for extended periods, use hands to handle or feel objects, tools, or controls, and talk or hear.
  • The employee is frequently required to stand, walk, reach with hands and arms, and stoop, kneel, crouch, or crawl.
  • The employee must occasionally lift and/or move up to 50 pounds.
  • Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
  • The employee may need to push, pull, or move objects and equipment, occasionally weighing up to 50 pounds.
  • The position may occasionally require physical activities such as walking and standing for extended periods during meetings or other events.