Under the direction of the Quality Improvement Coordinator and the Director of Quality Management, the Case Manager will perform required utilization reviews and data abstraction for all payor types in accordance with payor rules and the Case Management Plan. The Case Manager assists the physicians and providers in evaluating the patient for discharge needs as well as any discharge resources and assist in expediting the patient’s care. The Case Manager evaluates patient discharge needs and coordinates with the physician and other care team members to expedite appropriate discharge. The Case Manager may assist with abstraction of all required quality measures and ensure compliance with regulatory requirements. Keep current with changes in regulatory requirements and assist with staff and physician education regarding changes in quality measures. The Case Manager is responsible for facilitating the achievement of clinical, quality, and cost effective outcomes for patients presenting for care in the Emergency Department. The ED Case Manager takes the lead in coordinating community-based care and services to ensure that each patient receives appropriate and timely treatment at the most appropriate level of care, and to ensure all inpatient admissions meet criteria for medical necessity. The ED Case Manager also performs specific Utilization Management activities to support the patient flow process, comply with payor-specific requirements, and maintain consistency with professional and/or other regulatory standards.
Hours: PRN “as needed”
Days and hours would vary between Monday-Friday 8:00am-4:30pm
Education: Registered Nurse (RN) or Licensed Practical Nurse (LPN) with degree from an accredited program.
Experience: Five (5) years hospital nursing experience as a staff nurse and two (2) years experience in Utilization Review, DRG Management or ICD-10-CM coding.
Licenses, Certifications, and/or Registrations: Current active Alabama RN or LPN license. Current BLS certification.
Equipment/Tools/Work Aids: Telephone, mobile phone, pager, personal computer, laptop computer, internet, acute care criteria, discharge planning resources, encoder software, Meditech programs.
Specialized Knowledge and Skills: Must have knowledge of the utilization review process and regulations governing the Medicare/CHAMPUS prospective payment system or ability to attain working knowledge through independent study and/or through participation in related educational programs.
Must be familiar with Severity of Illness/Intensity of Service (SI/IS) criteria and must stay current with changes in review requirements. Must be familiar with Medicare medical necessity guidelines. Must have knowledge of JCAHO requirements and those of commercial insurance carriers. Must be dependable and self motivated with pleasant, personable manner. Must be able to communicate with physicians, hospital staff and physician office staff. Must be flexible, able to motivate others and organize workload. Must be able to develop rapport with medical staff and hospital staff in all departments and maintain a professional attitude at all times. Must have the ability to complete work thoroughly and accurately. Must be able to manage communications tactfully and respectfully. Must have legible, neat handwriting. Discharge planning experience or case management experience helpful.