RN Case Manager

The RN Case Manager reviews and monitor patient's utilization of health care services with the goal of maintaining high quality, cost-effective care. This role reports to the Director of Progressive care. The role includes providing the medical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures. This includes providing referral authorization, concurrent review, proactive discharge/transition planning, appropriate referral to case management, and high dollar claims review.

Essential Duties and Responsibilities

• Performs concurrent and retrospective reviews on all inpatient, facility and appropriate home health services. Monitors level and quality of care. Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs. In conjunction with, and under the supervision of physicians, evaluates and provides feedback to treating physicians regarding a member's discharge plans and available covered services including identifying alternative levels of care that may be covered.
• Presents hospital-patient status updates and addresses barriers to discharge/transition.
• Responsible for ensuring Swing Bed required components are met. Including, but not limited to; interdisciplinary planning, planning of activities, coordination of discharge care, and documentation.
• Monitors all utilization reports to assure compliance with reporting and turnaround times.
• Addresses care issues with Director of Progressive Care and Nursing Management.
• Coordinates an interdisciplinary approach to support continuity of care. Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services, as needed for patients.
• Coordinates identification and reporting of potential high dollar/utilization cases to reinsurer and finance department for appropriate reserve allocation.
• Consults with physicians, health care providers and outside agencies regarding continued care/treatment or hospitalization.
• Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
• Clarifies health plan medical benefits, policies and procedures for patients, physicians, medical office staff, contract providers, and outside agencies.
• Responsible for the early identification and assessment of patients for potential inclusion in a comprehensive case management program. Refers patients for case Management accordingly.
• Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the Hospital. Prepares CMS-compliant notification letters of non-certified and negotiated days within the established time frames. Reviews all non-certification files for correct documentation.
• Assists in the identification and reporting of potential Quality of Care concerns. Responsible for assuring these issues are reported to the Director of Clinical Quality.
• Work as an interdisciplinary team member within Medical Management and all other hospital departments.
• Provide back up for Social Services, when needed.
• Demonstrates clear ownership of workplace and patient safety.
• Reports mistakes, near misses, adverse events and quality and safety concerns.
• Participates in the development and implementation of safety and quality improvement activities.

• Other duties as assigned.

Job Requirements

Education: Graduation from an accredited School of Nursing required; Bachelor's degree preferred.

Certification/Licensure: Current licensure as an RN in the State of Indiana required.

Experience: Minimum of three (3) years of clinical experience as an RN required and 5 years managed care or equivalent health plan experience, preferred. Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulations, and correspondence; ability to write routine reports and correspondence; and ability to present information in one-on-one or to small groups. Must have excellent oral and written communication skills. Must have excellent computer skills and ability to learn new systems. Strong attention to detail, organizational skills and interpersonal skills.

Physical Requirements: Frequent sitting, walking and standing. Able to convey detailed or important instructions or ideas accurately to patients or their families. Ability to stoop, bend and reach. Occasionally required to lift and/or move up to 20 lbs.