RN/LCSW Case Manager

Company Job Overview:

The Case Manager is responsible for the coordination of health care decisions by using a systematic approach to assure treatment plans that improve quality and outcomes, coordination of care across the continuum; promotion of cost-effective care within the allotted time frame; assuring payments of hospital-based services meeting patient-related utilization management criteria, and implementation of safe and appropriate discharge plans.  

Company Job Duties

Performs management duties efficient and effectively. Demonstrates leadership and initiative in all daily activities. Provides professional example for staff in attitude, support of facility goals, and guest relations. Maintains a high level of case management expertise.  

Informs CEO of all major conditions, subsequent changes, and emergency situations. Submits accurate and thorough work on time. Completes data collection and tabulation of statistical information as directed.

Works cooperatively as a team member to identify and solve facility-wide needs and improve operations. Regularly participates in scheduled meetings.

Demonstrates compliance with facility-wide Utilization Management policies and procedures. Coordinates UR compliance with Quality Management to assure all licensure and accrediting requirements are fulfilled.

Assures medical necessity review criteria, as mandated by the QIO, is implemented for all admissions and continued stays. Assures thorough and timely completion of utilization review and non-Medicare utilization. Completes referral Pre-Admission Medical Necessity reviews within two hours of receipt.  

Facilitates effective, open communication between staff and Case Management. Demonstrates sensitivity and responsiveness to employee issues, and resolves situations effectively and in a timely manner. Delegates responsibility to staff members appropriately.

Stresses Payor/Referral satisfaction. Effectively interacts with patients, families, and visitors to enhance guest relations. Represents the facility in all contacts with other health professionals and the general public in a manner which enhances the facility’s reputation. Meets payor requirements by assuring all insurance certifications are timely. Assures payor/referral satisfaction with Case Management to promote repeat business. Assures team is notified immediately of payor requirements.

Maintains an up-to-date community resource system and assists patient and family in gaining knowledge of, and access to, appropriate services.

In conjunction with the Clinical Services Department, assures clinical documentation is in accordance with payor guidelines for reimbursement.

Follows correct company procedures when dealing with patients and families. Assures team and family conferences are conducted according to policy and procedure. Assures team conference reports are professional and appropriate in conjunction with clinical services. Identifies and manages outside testing and procedures.

Assures discharge planning evaluations are completed with 72 hours of admission. Discharge section to be completed with 24 hours of discharge.

Maintains fiscal responsibilities. Assures department is identifying and negotiating the fullest possible reimbursement to maximize insurance benefit coverage for the patient. Completes Lead Case Manager reports/duties in Lead Case Manager absence or as instructed. Reviews insurance verification form to minimize risk.    

Provides payor-friendly options to promote prompt payments while reducing facility's financial risks. Assures day end charge reports are reviewed for all patients. Completes CBO billing, within required time frame, accurately and thoroughly. Communicates any billing or payor concerns to CBO as needed. Participates in accounts receivable conference calls with CBO.

Assures thorough and timely completion of critical payor information in the HMS commercial UR system. Submits accurate projections weekly of commercial to Corporate finance. Assures Billing and Reimbursement form is completed (and signed if indicated) within 24 hours for all commercial patients admissions. Reviews insurance verification form to minimize risk.