CASE MGR-SWING BED CRD

Job Summary:

• The Case Manager plans, coordinates, develops, evaluates, and monitors the care of an assigned group of patients to achieve quality, cost-effective patient outcomes. The case manager works collaboratively with interdisciplinary teams to identify services required to meet the patient/family needs throughout the continuum of care while ensuring that appropriate resources are implemented in a timely manner.
• Meets with all new admissions to identify and discuss a proposed discharge plan and follows the discharge plan's progress until discharge. Provides case management to improve the placement of patients in the most appropriate care setting. Collaborates with physician and registration staff regarding the correct level of care assignment, medical necessity, and medical review policies to validate appropriateness of admission, services, and continued stay and, if necessary, issue letters of non-coverage.
• Reviews scheduled Medicare outpatient surgeries for compliance with the APC “Inpatient Only” listing. Collaborates with Physician Advisors, the Chief Medical Officer, and the attending physician for questioned admissions to ensure an expedited appeal process. Evaluates the use of observation bed services to ensure that patients are either admitted to a higher level of care or discharged in a timely fashion to decrease our potential loss of reimbursement for Medicare observation services and other payors. Performs timely reviews concurrently on assigned patients relative to the prospective payment system for Medicare, Medicaid, private payors, and other hospital utilization management applications. Serves as the initial contact healthcare providers have with the process of DRG assignment.
• Functions as the central liaison between the Medicare QIO, review agencies, Business Services, Patient Accounts, and other healthcare professionals affected by concurrent review, DRG assignment, the certification process, and discharge planning. Is involved in utilization review activities as defined by the Utilization Management. Participates on various committees/ task forces as needed. Obtain working diagnoses and procedure codes and a working DRG as needed. Monitors denials and assist with the appeal process as required. Assembles, analyzes, monitors, and tracks data for reporting as designated by the Director.
• Responsible for the Swing Bed admission and Minimum Data Set (MDS) Coordination. Maintains schedules for completing the Resident Assessment Instrument (RAI) within allowed time limits by current Federal, State, and Local regulations and submission to payor sources within allotted timeframes. The Case Manager shall implement the nursing process in an organized, systematic manner to include assessment, planning, intervention, and evaluation as evidenced by documentation in Patient Care Record, care plans, and completion and submission to CMS of Minimum Data Sets in a timely and accurate manner.
• This job description is not intended to be all-inclusive; the employee will also perform other reasonably related job duties as assigned.

Performance Expectations:

• Demonstrate the aptitude to deal with multiple tasks.
• Demonstrate the ability to adapt to change.
• Demonstrate the ability to manage daily workload.
• Demonstrate the ability to learn and follow various regulatory guidelines.
• Demonstrates knowledge and skills to appropriately communicate and interact with patients, families, and visitors while being sensitive to their cultural and religious beliefs.
• Demonstrates communicating effectively with staff, managers, physicians, and the executive team.
• The individual must be able to type and be familiar with the rules of spelling, grammar, and punctuation.
• The individual must have the ability to use a copier, telephone, and personal computer.
• Workable knowledge of CMS Conditions of Participation and other regulatory systems is essential.
• Workable knowledge of correct coding procedures, InterQual criteria, Milliman Care Guidelines (MCG), Perspective Payment System and medical terminology is necessary.

Qualifications:

Work Experience:

Three or more years of experience in clinical nursing is required.

Three or more years of experience in clinical respiratory required.

Case Management and /or Utilization Management experience preferred.

Certification/Licensure-DUE UPON HIRE

• Licensed RN able to practice within the State of MS

• Licensed CRT/RRT able to practice within the state of MS

Additional Certification/Licensure - Obtained based on required timeframe below

• Basic Life Support

Within 30 Days of Employment

Required

Mental Demands:

Exceptional oral and written skills are required to relate effectively to hospital staff, physicians, physician office staff, and review agencies. Ability to perform as a team member, cooperate with others, follow directions precisely, demonstrate initiative, set priorities, and function under stress. The individual must have a high energy level and be capable of handling pressure both mentally and physically.