Case Manager I
4 weeks ago
Job Summary:
Sharp HealthCare is seeking a skilled RN Case Manager I to join our team. As a key member of our healthcare team, you will be responsible for assessing, developing, implementing, coordinating, and monitoring a comprehensive plan of care for each patient/family in collaboration with the physician, social worker, and all members of the interdisciplinary team.
Key Responsibilities:
- Conduct initial review at POE or within 24 hours of admission utilizing appropriate evidenced-based care guidelines software.
- Identify anticipated LOS and document as per departmental process.
- Conduct daily concurrent reviews per protocol/policy and payer request.
- Utilize appropriate care guideline software to identify the correct patient status and level of care.
- Work with attending provider to assure correct status, if status and order does not match; works with provider to resolve conflict and document interventions in the EMR.
- Assure correct documentation is present for 2MN benchmark and presumption.
- Assure Medicare Inpatient to observation status changes follow Condition Code 44 requirements.
- Actively works observation patient list assuring transitions to next level of Care.
- Communicates as indicated with third-party payers to obtain necessary authorization for reimbursement of services.
- Refer defined cases for medical secondary review and share findings with providers.
- Provide advice to Revenue Cycle/HIM regarding RAC decision to appeal, denials, input into appeals, share findings with providers.
- Review all cases with readmission within 30 days; report findings in the EMR and in accordance with the departmental policy.
- Identify opportunities for cost reduction and participate in appropriate utilization management venues.
- Escalate and refers cases for consultation with Physician Advisor or Medical Director as appropriate.
Requirements:
- 2 Years Recent acute care nursing experience, case management experience or equivalent experience in the healthcare setting.
- California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED
- Bachelor's Degree in Nursing or equivalent degree.
- Master's Degree.
- Certified Case Manager (CCM) - Commission for Case Manager Certification -PREFERRED.
- Accredited Case Manager (ACM) - American Case Management Association (ACMA) -PREFERRED.
Preferred Qualifications:
- Excellent interpersonal skills, as demonstrated by the ability to work effectively with individuals and or teams, and across disciplines.
- Excellent communication and negotiation skills as demonstrated in oral and written forms.
- Ability to work in a collaborative partnership model with Social Workers and other members of the interdisciplinary team, both internal and external.
- Organizational and time management skills, as evidence by capacity to prioritize multiple tasks.
About Sharp HealthCare:
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class.
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