Job Description

• Pre-Certification & Authorizations: This Position requires multi tasking to insure authorizations received at the highest level of reimbursement and as quickly as possible for admission.
• Case Manager will be responsible for processing skilled nursing referrals to include insurance verifications, cost analysis when applicable.
• Communicate with the insurance case managers to obtain authorization for correct level of care according to the patients needs under the reimbursement guidelines provided by patient's benefits and current managed care contract.
• Ensure highest level of customer service to the managed care plan.
• Provides facility case management/utilization review and discharge planning to assure that the patient progresses through the continuum of care and is discharged to the least restrictive environment.
• Coordinate the integration of the social service function into patient care.
• Coordinate the facility activities concerned with case management and discharge planning.
• Adhere to departmental goals, objectives, standards of performance, and policies and procedures.
• Ensure compliance with quality patient care and regulatory compliance.
• Provide effective timely communication to insurance plans to facilitate best possible functional outcome with resources available within the patients benefit structure.
• Coordinate the integration of social services/case management functions into the patient care, discharge, and home planning processes with other facility departments, external service organizations, agencies and health care facilities.
• Conduct concurrent medical record review using specific indicators and criteria as approved by medical staff, CMS, and other state agencies.
• Acts as patient advocate: investigates add reports adverse occurrences, and performs staff education related to resource utilization, discharge planning' and psychosocial aspects of health care delivery.
• Promote effective and efficient utilization of clinical resources.
• Mobilizes resources and interviews, as needed, to achieve expected goal to assist in achieving desired clinical outcomes within the desired time-frame.
• Ensure that patient tests are appropriate and necessary and are carried out within the established time-frame and that results are promptly available.
• Conducts review for appropriate utilization of services from admission through discharge.
• Evaluate patient satisfaction and quality of care provided.
• Initiates and presents "denial letters", as appropriate.
• Assesses patient care required throughout continuum of care for diagnosis, procedures and reimbursement guidelines.
• Communicates with Interdisciplinary team at regular intervals throughout Skilled Nursing and Rehabilitation stay and develops an effective working relationship.
• Assist Interdisciplinary team to maintain appropriate cost, case, and desired patient outcomes.
• Complete expanded assessment of patients and family needs at time of admission.
• Assess patient's progress through expected hospital course.
• Refers cases where patients and/or family would benefit from counseling required to complete complex discharge plan to social worker or facility Director of Nursing.
• Serve as a patient advocate. Enhances a collaborative relationship to maximize the patient's and family's ability to make informed decisions.
• Facilitates interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family education and identified post-admissions needs.
• Collaborate with clinical staff in the development and execution of the plan of care, and achievement of goals.
• Directs and participates in the development and implementation of patient care policies and protocols in order to provide advice and guidance in handling special cases or patient needs.
• Coordinates the provision of social services to patients, families, and significant others to enable them to deal with the impact of illness.

Qualifications:

• Must hold a current and active valid RN or LPN license in the state employed
• One year of clinical experience. Experience with MDS completion, reimbursement, clinical resource utilization is highly desirable. AANAC membership and RAC-CT certification is strongly recommended.
• Graduate of an accredited school of nursing. Bachelor of Science Degree in Nursing is preferred.

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