Category:RN ProfessionalCity:JacksonState:TennesseeShift:8 - DayJob Description
Care Management Case ManagersProvides leadership in the coordination of patient-centered care across the continuum, develops a safe discharge plan through collaboration with the patients / caregivers and multidisciplinary healthcare team to arrange appropriate post discharge services and optimal transitions in care. Facilitates appropriate LOS, patient satisfaction, and reimbursement for all patients. Develops and maintains collaborative relationships with all members of the healthcare team.
Through clinical care coordination drives efficient utilization of resources to reduce length of stay, improve patient flow and throughput, limits variation by applying innovative and evidence based practice, and to reduce the risk of readmission. ESSENTIAL JOB FUNCTIONS:Obtains or ensures acquisition of appropriate pre-certifications authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party payer guidelinesObtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirementsDocuments, monitors, intervenes/resolves, and reports clinical denials/appeals and supports retrospective payer audit denials; collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor, and third party payers, etc.
Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory requirements, etc.; serves as an educational resource to all WTH staff regarding utilization reviewAssumes roles in assessment physical, psychosocial, & economic needs for transition of care planning to a variety of levels of care; delegates to others as appropriateDocuments, verifies, and validates specific data required to monitor and evaluate interventions and outcomesInterviews and collects patient specified data and chart review related to readmission and appropriately notifies care teamCommunicates telephonically and electronically with outpatient providers in an effort to enhance the continuum of careIntegrates performance improvement principles and customer service excellence principles into all aspects of
; practice and governmental commercial payer guidelinesAdheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodiesAssumes responsibility for WTH required continued education and owns professional growthPerforms other duties as assigned or requiredJOB SPECIFICATIONS:
Bachelor of Science in Nursing preferred. Associate or Diploma of Nursing requiredLICENSURE, REGISTRATION, CERTIFICATION:Current licensure as Registered Nurse in the state of Tennessee. AHA Basic Cardiac Life Support preferred.
ACM, CCM or other certification applicable to Case Management within 3 years of hire preferredEXPERIENCE:Minimum 3 years of recent acute clinical care experience preferredPreferred experience in care facilitation and management and utilization reviewKNOWLEDGE, SKILLS AND ABILITIES: Strong communication skillsAbility to develop and maintain positive relationships with customers internal and external to WTH EnterpriseCare coordination / discharge and transition planning and community resource knowledge preferredNONDISCRIMINATION NOTICE STATEMENTWe are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, ethnicity, disability, religion, national origin, gender, gender identity, gender expression, marital status, sexual orientation, age, protected veteran status, or any other characteristic protected by law.