Standard Hours 24.00 More information about this job: Responsibilities:
Responsible for the assessment, planning, implementation, monitoring and evaluation of case management services through the appropriate utilization of resources. Application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes. Utilizes independent critical thinking and decision making to formulate coordination of care and address patient's discharge needs.
Utilization Management - Utilizes Payor specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity in the acute care setting. Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues. Identify and manage concurrent and retroactive denials through communication with attending physicians, external physician resource group and payors.
Documentation - Appropriate and complete documentation of clinical review and transitional plan in the medical record, and denial management in the case management documentation system and in the billing system.
Care Coordination - Coordinates appropriate care through clinical assessment and patient advocacy. Communicates and educates patient, family and healthcare team on the plan of care and post-acute transition options ensuring patient freedom of choice. Makes appropriate referrals within the scope of available benefits to facilitates a safe transition to the post acute setting.
Compliance - Understands and applies applicable federal and state regulatory requirements. Educates patients, families, and healthcare team to facilitate Virtua compliance with these requirements. Prepares for audits by applying appropriate screening tools and documentation. Identifies and reports compliance issues as appropriate.
Participates in organizational improvement activities, including patient satisfaction teams, six sigma teams, departmental/divisional teams, and community events.
Position Qualifications Required
Required: Must be RN or Licensed Social Worker
Preferred: 3 years clinical nursing (RN) experience and 1 year UR/CM/QM experience or 3 years experience as Clinical Social Worker. Basic understanding of Medicare, Medicaid and managed care. Discharge planning or home health background
Excellent verbal and written communication skills, problem solving, critical thinking and conflict resolution.
Graduate of an accredited School of Nursing or Graduate of an approved School of Social Work with a Bachelor's or Master's Degree.
Licensure and/or certification from the State of New Jersey as a Social Worker or Registered Nurse.
PT 24hpw, 3 8 hr shifts per week, dayshift, MCH EXPERIENCE REQUIRED, BSN< RN or Social Worker (hospital based experience and utilization review experience preferred).
Virtua Health - 2 years ago
Virtua Health is a multi-hospital healthcare system headquartered in Marlton, NJ. Its mission is to deliver a world class patient experience...