Job Duties Include:
The Case Manager RN is responsible for the authorization and utilization management of skilled home care services for contracted membership from admission through discharge. Works cooperatively with Network Providers, patients, discharge planners and all other healthcare providers who have mutual care interests in insuring that the patient achieves optimal and timely services. Documents and communicates clinical information pertaining to the episode of care in a timely manner to appropriate personnel.
Using clinical and demographic data, determines appropriateness of requested services and authorizes same based on benefit eligibility guidelines and in accordance with NHS’s SOP. Receives and communicates to appropriate healthcare providers treatment orders, ensuring accuracy and completeness of information. Provides clinical updates to appropriate Plan and Provider personnel in a timely manner as appropriate. Documents updates and communications within the clinical data base. Works in concert with Plan Case Managers to evaluate effectiveness of treatment plan, makes recommendations when appropriate for revisions to the Plan, and authorizes services based on Plan approval.
Verifies insurance benefits with each new referral and all re-authorizations. Acts as a ready resource to staff to address clinical questions, process and/or procedure questions as they arise. Assists with orientation of new staff when requested. Actively support’s customer service relations through appropriate interactions with divisional support staff, patients and clients of NHS. Reports real/potential issues/concerns with patients, families, physicians, referral sources, vendors, and/or support services to the Executive Director or Network QI Coordinator in a timely manner. Works with the Executive Director and QI Coordinator to identify appropriate corrective action and implementation plans when requested. Assumes supervisory responsibilities in the absence of the Network/QI Coordinator and the Clinical Operations Supervisor. Rotates with the other Care Managers to provide 24/7 clinical support to the after hours program’s primary on-call personnel.
- Licensed professional in the state of employment and at least 2 years of experience in med-surge direct patient care.
- Required licensure in Nursing as granted by the current state of practice.
- At least 2 years of experience in med-surge patient care.
- At least 2 years of experience in home career related environment.
- Experience applying appropriate clinical knowledge to utilization management decisions.
- Experience developing ways of accomplishing goals with little or no supervision, depending on oneself to complete objectives and determining when escalation of issues is necessary.
- Experience applying knowledge of medical reimbursement processes.
- Basic email skills, internet explorer (sending, receiving, and organizing communications).
- Experience entering data into databases (ex: MS Access).
At least 2 years of experience in home care or related environment.
Walgreens - 14 months ago
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