Position Summary
Provides case management as well as routine discharge planning services to patients and their families, to facilitate safe and timely discharges, to enhance the benefits of medical care, to ensure hospital reimbursement, to provide cost effective acute care and to ensure continuity of care.
Job Duties
- Reviews all patient charts within 24 to 48 hours of admission to assess appropriateness of admission, intensity of service and potential discharge needs in accordance with the utilization/contractual requirements.
- All questionable cases (i.e. inappropriate admission, level of care changes, quality issues) will be communicated to the Attending Physician. If no resolution, CM will refer the cases to the Physician Advisor.
- Communicates with insurance providers for admission and continued stay reviews as stipulated by contract in order to certify the patients' stays. Contacts the Attending Physician to obtain additional clinical information on the case to minimize denials and to assist with reimbursement of care and/or appeals.
- Denied day cases will automatically be referred to the Physician Advisor.
- Participants in Interdisciplinary D/C Rounds to concurrently and collaboratively review and facilitate the patient's plan of care. Acts as liaison to assist in identifying opportunities to improve care.
- Keeps Director of Case Management abreast of problem areas and seeks guidance in a timely manner.
- Effectively coordinates care with ancillary departments and attending physician (i.e. rehabilitation, laboratory, radiology, etc.) to ensure timely provision of care and to decrease length of stay and appropriate treatment and discharge.
- Performs other job duties and responsibilities as assigned.
Qualifications and Skills
- Knowledge of Utilization Review criteria to include Interqual and/or Milliman preferred.
- Knowledge in Medicaid, Medicare, Managed Care review and documentation requirements. Is knowledgeable of state and federal regulations, DNV standards and practices for acute care facilities.
- Excellent written and verbal communication skills.
- Knowledge in discharge planning and length of stay initiatives.
- Knowledge of home care and referral process.
- Expert critical thinking and problem solving skills.
Education, Experience and Certification/Licensure Requirements
- Current RN license in the state of NJ.
- Minimum 1- 2 years direct patient care experience in an acute care hospital
- Previous case management experience preferred.
