The Case Manager reports to the Regional Director and is responsible for the oversight of pre-certification, patient care management, discharge planning, and health plan compliance within the centers.
Monitor inpatient, outpatient, and SNF patients and initiate patient care arrangements. Report findings to Medical Management, Medical Director, and Physicians. Responsible for patient care management to assure appropriate care is provided; reinforce patient education regarding preventative care, dietary restrictions, medications and other therapeutic regimens; coordinate home health and DME requests and provide recommendations to the PCP and Medical Director. Provide oversight in patient care evaluation, coordinate the collaboration of the Primary Care Provider and Consultants, and make suggestions to improve plans to meet patient needs. Assist with the monitoring of utilization management and make recommendations regarding effectiveness of health care resources, trending and intervention. Assist in the assessment of clinic operations and make recommendations as necessary. Assure compliance with CMS guidelines and covered health plan service guidelines. Assist with the contestation of Part A and Part B claims as needed. Consistently apply guidelines to the medical record review process. Evaluate and recommend health delivery network changes with the Medical Director, PCP and Medical Management Team. Participate in QI projects. Attend Case Management meetings, POD meetings and other meetings as requested. Participate in patient satisfaction programs. Follow up on all inpatient/outpatient discharges. Assist PCP, Medical Management and Medical Director with the management of high-risk patient populations and appropriate case management plans. Other duties as assigned.
- LPN/RN license in the State of Florida
- Ability to perform case management
- Knowledge and skill in the applications of the techniques and practices of the nursing profession
- Ability to explain medical instructions to patients and their families
- Ability to learn and understand appropriate Federal, State, and local regulations, and follow company policies and procedures
- Ability to interact and deal tactfully with the public
- Ability to read, write, speak and understand the English language fluently
- Ability to communicate effectively, establish and maintain an effective working relationship with patients, families, physicians and staff and deal effectively and professionally under pressure
- Ability to travel locally
- Must maintain consistent, punctual and reliable attendance
- Bilingual a plus (English/Spanish)
JSA Healthcare Corporation - 17 months ago