Job Summary:

Seeking an experienced case manager with 5 years of experience in an acute hospital setting.

Qualifications:

* Experience

* 5 years of experience in managed care

* Substantial clinical experience

* Education

* Bachelor's degree (required)

* Masters (preferred)

* Licensing

* Foreign Medical Graduate or Registered Nurse (preferred)

* CCM (Certified Case Manager) (preferred)

* ACM (Accredited Case Manager) (preferred)

* Bilingual (English/Spanish) (preferred)

Responsibilities:

* Performs and documents patient assessment within 24 hours of admission

* Checks prior authorizations initiative by admitting

* Knowledge navigating and using payer portals

* Performs concurrent reviews

* Contacting all HMO's on a daily basis and provides clinical information to obtain insurance authorization for the patient's admission and continued stay

* Indicates the appropriate level of care and utilization of services needed

* Establishes criteria for medically necessary services

* Knowledgeable of Milliman Care and Interqual Guidelines

* Develops a plan of care for patients from admission to discharge.

* Promotes the most efficient and cost-effective use of services

* Curtails the performance of inappropriate and/or duplicate services

* Encourages standardization of medical practice patterns

* Enhances the quality of healthcare

* Performs concurrent reviews for patients to ensure that extended stays are medically justified and are documented in patient's medical records.

* Calculates and manages the lengths of stay and continued-stay days for patients.

* Evaluating the patient's condition and readiness for discharge planning

* Develops discharge plans

* Communicate and assist the physicians in the planning and coordination of patients discharge planning

* Management of transfer procedures

* Management of the guardianship process

* Able to discuss and educate patient/family regarding discharge planning and resources available after discharge. Clearly specifies all the information discussed with the patient and/or family regarding the patient's discharge plan.

* Participates in PI programs through the identification of opportunities for improvement, data collection, evaluation of findings, improving the process, applying knowledge and incorporates into practice

* Scheduling Peer-to-Peer reviews with payors

* Proactively identifying and resolving issues that could lead to denials

Skills:

* Familiarity with Medhost electronic medical records

* Extensive medical knowledge

* Self-driven (work and education)

* Keeps knowledge up to date by reading literature and participating in outside continued education meetings, training, and conferences

* Working knowledge of regulatory agencies

* Excellent human relations and communication skills (verbal and written) to maintain good rapport and effective working relationships with medical staff, nursing staff, and other ancillary department staff throughout the hospital

* Excellent organizational skills and attention to detail

* Ability to convey care plan to physicians and the medical team

* Proficient with Microsoft Office Suite or related software.

* Integrity

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