RN - Case Manager - Full Time

Job: RN-Case Manager  

Classification: Hourly/Non-Exempt 

Job Category: 2 Professionals 

Position Summary 

The RN Case Manager monitors and compiles information on the necessity of the admission of patients and on the continued stay of patients. The Case Manager oversees the utilization management of each patient, conducts reviews, and ensures proper status of patient.  

Essential Functions 

-Knows and conforms to the Texas Nursing Practice Act, the Boards’ rules and regulations as well as Federal, State, or local laws, rules, or regulations affecting the RN's current area of nursing practice. 

-Reviews inpatient records for admission necessity, justification of continued stay.  Maintains complete documentation. 

-Demonstrates clinical knowledge to assist physicians in providing complete documentation of severity of illness and intensity of services to assure that criteria for acute hospitalization are met.  

-Acts as a resource for medical staff, interpreting requirements of federal, state, and third-party payer guidelines for coverage. 

-Demonstrates ability to prioritize activities according to urgency of potential utilization problems on daily basis.   

-Adapts effectively to changing priorities. 

-Completes work assignments on a timely basis and junctions effectively with minimal supervision.   

-Interacts appropriately with physicians to achieve utilization objectives.   

-Communicates effectively and professionally with the medical staff, other hospital departments and outside organizations. 

-Assures timely notification of inappropriate admissions and assists in documenting administrative determinations 

-Maintains required logs of utilization activity according to hospital procedures and requirements of third-party payers as needed.   

-Provides ongoing support in preparation of required documentation for management and other review committees.   

-Assists in the preparation of and delivers denial letters in cases of non-covered admissions.   

-Provides timely completion of required utilization review certification for billing, including private insurance certifications.   

-Oversees audits and assembles record and necessary utilization review documentation for audits and surveys by third party payers in conjunction with the denial management team.   

-Keeps director abreast of actions with patient, physicians/administrators, etc. 

-Able to work within EPIC and Indicia with adeptness and ease.   

-When requested, assists the director with special projects.   

-Effectively copes with emergency situations and resolves them in a positive manner. 

-Has knowledge of registration department functions. 

-Responsible for own continuing competence in nursing practice and individual professional growth.   

-Provides documentation to third-party payers that require clinical information to certify medical necessity prior to payment of services rendered. 

-Notifies the appropriate personnel and physicians when there is a denial for medical necessity.  

-Participates in the daily huddle and coordinates care of the patient with the whole team.   

-Demonstrates an understanding of the operation of a health care computer system.  

-Performs general clerical duties as needed.  

-Demonstrates knowledge of utilization and financial issues of an acute health care facility.  

-Demonstrates effective oral and written communication skills.