CARE MANAGER-RN
Location: Pittsfield, Maine
Description: Sebasticook Valley Hospital is presently looking of CARE MANAGER-RN right now, this occupation will be depute in Maine. For detail informations about this occupation opportunity kindly read the description below.
(INTERNAL ONLY)
A. JOB PURPOSE:
Provides leadership in the coordination of patient-centered care across the continuum, develops a safe discharge plan through collaboration with patients, families, care givers, and the multidisciplinary healthcare team to arrange appropriate post discharge services and optimal transitions in care. Additionally, the role of the nurse care manager is to maintain revenue integrity and compliance as outlines within the hospital Conditions of Participation. Essential functions of the role of utilization review are outlined in job responsibilities.
B. JOB RESPONSIBILITIES (Essential Job Functions)
- Screening for medical necessity upon admission, concurrently and retrospectively.
- Assisting providers in assuring documentation accurately reflects the plan of care, barriers to care ect...
- Ensures that required documentation is completed per Conditions of Participation such as but not limited to; IM; Choice letters (ROI), MOON and swing bed admission and discharge paper work.
- Manages den ials and appeals, peer to peer discussions, and high awareness of under and over utilization of services, managing concurrent denials, reviewing and assuring accurate status order is on the record, physician and peer education of levels of care.
- Obtains or ensures acquisition of appropriate pre-certification authorizations from third party payers and placement to appropriate level of care level of care prior to hospitalization utilizing medical necessity criteria and third party payer guidelines. This includes all aspects of swing bed program.
- Obtains or facilitates acquisition of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and within compliance with all regulatory and contractual requirements.
- Focuses on Length of Stay (LOS) management.
- Assumes roles in assessment physical, psychosocial, and economic needs for transition of care planning to a variety of levels of care.
- Documents, verifies, and validates specific data required to monitor and evaluate interventions and outcomes (such as readmissions).
- Participate in the discharge planning activities to ensure timely coordination of clinical case management occurs.
- Functions as resource to all members of the health care team as well as the patient and/or family members regarding the care management/utilization review management function.
- Collect, analyze and report relevant Utilization Review Management data/information to appropriate Committees.
- Integrates performance improvement principles and patient experience into all aspects of job responsibilities.
- Facilitates coordinate consults for swing patients i.e. Social Work, Dental, Wound Management, etc.
- Participate in the orientation of staff and physicians in the area of utilization review management and care management.
- Any additional duties as assigned.
C. MINIMUM QUALIFICATIONS:
Education: Registered Nurse with current Maine license. BSN preferred
Experience: Minimum of three (3) years clinical experience â€" Care Management experience preferred or a broad base of clinical practice working in the areas of Utilization Review Management/Care Management with knowledge of performance improvement/risk reduction strategies. ACM, CCM or other certification applicable to utilization management within 3 years of hire.
Training: Knowledge of utilization and performance improvement processes, payor perspectives, and regulatory agencies' standards and regulations in these areas. Core coordination, discharge and transition planning and community resource knowledge preferred.
Licensure: Current Maine State License as R.N. BLS required.
D. JOB COMPETENCIES (Include Age Specific requirements for clinical workers):
a) Ability to apply knowledge of UR/Care Management & clinical practice processes.
b) Excellent verbal and written communication skills.
c) Well organized with an ability to manage and prioritize multiple tasks to successfully achieve desired results.
d) Team player, strong patient experience focus, leadership aptitude, ability to influence others and affect positive changes to improve all aspects of the clinical practice processes.
e) Ability to link functional areas of responsibility to operational strategies.
f) Strong computer skills, word processing, spreadsheets, databases and ability conduct meaningful presentation.
g) Highly self motivated and directed, hands on employee.
E. CONTACTS
Reports to: Director of Care Transitions
Directs Work of Others: None.
F. AMERICANS WITH DISABILITIES ACT REQUIREMENTS
Environment Demands/Exposure to Hazard:
Exposure to body fluids, contagious diseases.
Physical Demands:
Walking, sitting, standing.
Good vision, acceptable hearing.
Eye fatigue from computer and chart review.
Mental Demands:
High stress at times.
Work independently, make appropriate decisions.
Manual Dexterity Required:
Good ey e and hand coordination.
Good digital dexterity, typing (keyboard)
G. AMERICANS WITH DISABILITIES ACT STATEMENT:
External and internal applicants, as well as position incumbents who become disabled, must be able to perform the essential job specific functions (listed within each job specific responsibility) either unaided with the assistance of a reasonable accommodation to be determined by the organization on a case-by-case basis.
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This occupation will be started on: Fri, 04 May 2018 00:42:03 GMT