This position is responsible for oversight of resource management, discharge planning, care facilitation, utilization management and related duties by working collaboratively with the multidisciplinary team to achieve desired clinical, service and cost outcomes. The incumbent ensures that patients presenting for treatment are assigned the appropriate patient status and level of care, and obtains authorization from third party payors in order to expedite the receipt of full and timely reimbursement. They provide valuable information for consideration in clinical decision-making, patient throughput (UM) and discharge planning. The functions of this position exist to promote quality patient care and to prevent costly payment denials and reduce the institution's financial risk. QUALIFICATIONS/KNOWLEDGE/SKILLS/ABILITIES
- Requires 3-5 years experience in Case Management; Certified Case Manager preferred.
- Requires strong clinical background in acute care.
- Requires knowledge of InterQual Acute Level of Care Criteria and Federal guidelines outlining coverage of inpatient and outpatient hospital services, including observation.
- Requires computer experience.
- Requires knowledge of managed care and government healthcare benefits.
- Requires the ability to comprehend third party contractual arrangements.
- Requires understanding of the third party denial and appeal process.
- Requires strong interpersonal skills; communication skills and the ability to work independently.
- Requires strong organizational skills and the ability to lead a process from beginning to completion.
- Requires the ability to communicate and resolve conflict with physicians, other health care team members, community agencies, clients and families with diverse opinions, values and religious/cultural ideas.
- Requires excellent negotiation skills and the ability to facilitate multiple partners in the multi-disciplinary team.
- Requires the ability to identify and communicate cost and quality issues related to patient care.
- Requires strong analytical and critical thinking skills.
- Requires current state of Indiana nursing license; Bachelor's degree preferred
- Requires current state of Indiana nursing license; Bachelor's degree preferred.
Ball Memorial Hospital - 2 years ago
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