(Only QUALIFIED Healthcare Professionals accepted) Case Manager-RN – RN Case Manager – Case Management
The Manager of Case Management assumes 24-hour responsibility and assists with the direction, management, and evaluation of the Case Management|Social Work departments.
Reports to the Director of Case Management and assists with clinical, operational, and financial aspects of the Case Management|Social Work departments.
Manages all aspects of Case Management and Utilization Management, including admission and continued stay medical necessity reviews, payer authorization, discharge planning, denials management, and ensures adherence to the case management plan.
Assists with hiring, training, directing, development and evaluating of staff.
Assists with development of action plans, and may report outcomes to the Case Management Director, CNO, or others as applicable.
Assists with the design, implementation, training, and resources for the Case Management system for the organization.
Evaluates personnel, assesses environment, and determines priorities for care in order to plan, implement, and evaluate outcomes of care.
Evaluates the effectiveness of existing clinical protocols and pathways and makes recommendations for new ones.
Works effectively with MCO staff and leadership to decrease denials or downgrades in reimbursement.
Ensures collaboration among health care providers across the Continuum of Care to maximize effective access and efficient utilization of resources.
Minimum 5 years work experience post-graduation of an accredited school of nursing required
Five (5) years acute care nursing experience preferred
At least one year experience in case management, discharge planning or nursing management, preferred
Bachelor of Science in Nursing (BSN) required
Masters Degree in Nursing or related preferred
Registered Nurse License required
Current BCLS (AHA) certificate, preferred
Knowledge of Milliman Criteria and InterQual Criteria preferred
Behavioral Violence Prevention Training within 3 months of hires and maintain current required
Must be able to use independent decision-making skills in a wide variety of situations
Frequent contact with employees, physicians, customers, community individuals and volunteers
Must be self-motivated to complete work in a timely manner to meet deadlines
Experience with Core Measures, Quality Indicators, Case Management, and Utilization
Knowledge base of InterQual criteria
Knowledge of Managed care trends, Medicare, and Medicaid regulations
Advanced negotiation and mediation skills