Internal Case Manager

Area of Interest : Nurse Management
Position Type : Full Time - Permanent

Recruiter : Krawczynski, Paul
Job Description : Glendale Center, a 120 bed skilled nursing facility located in Naugatuck, CT, is currently interviewing RNs for an internal case management position.


POSITION SUMMARY: Responsible for the promotion of quality, cost-effective services and care through a collaborative process that coordinates, monitors, and evaluates services accorded to all transitional patients admitted to the assigned Genesis ElderCare Center.

RESPONSIBILITIES/ACCOUNTABILITIES:
1.Financial Role:
1.1Provide current, accurate and complete clinical information to payor
1.2Be familiar with third party reimbursement, insurance coverage and contract requirements
1.3Communicate financial and statistical information to Genesis ElderCare Center, Business Office and Managed Care Billing
1.4Negotiate for appropriate continuation of length of stay or extension of services and appropriate Level of Care rates
1.5Assess available resources to optimize resource utilization
1.6Facilitate obtaining payor authorization for recommended treatments, procedures, supplies, equipment and excluded medications
1.7Assist in identifying alternatives/solutions to uncovered services
1.8Assist Center in responding to denial of payment by providing clinical information that substantiates the need for continued coverage.
2.Resource Management:
2.1Assess patient/family risk factors as it relates to resource utilization: chronicity, complications and comorbidity and identify barriers to a timely discharge
2.2Act as resource to physicians, NPs and Treatment Team to identify alternate, cost-effective treatment options
2.3Review Pre-Placement Assessments to identify costly treatments, supplies or services and assist staff in obtaining authorizations
2.4Identify overuse or resources such as rehabilitation therapy, diagnostic studies, nonformulary medications and medical supplies
2.5Review Admission orders on all managed care patients for appropriateness and notify responsible personnel when duplicate services are ordered
2.6Verify that the "Care Management Client" form is correct for contracted vendors to be used for needed patient services
2.7Clearly communicate contract inclusions and exclusions to Treatment Team as necessary
2.8Utilize standard review forms and language for Treatment Team documentation to comply with payor requirements
2.9Maintain and submit utilization data/information/reports as requested by Managed Care Operations or the Manager of Internal Care Management
2.10Advise Center of changes in reimbursement mechanisms
2.11Identify practice patterns within the Center that contribute to high resource utilization and report to Manager of Internal Care Management
2.12Monitor changes in status that could lead to hospital readmission and report to nursing
2.13Develop and implement discharge plan to include responsibilities of nursing, rehab and social service staff and communicate plan to payor, staff and customer/family as necessary
2.14Consult Social Worker immediately for all identified social, customer/family problems that are identified as barriers to a timely, appropriate discharge.
3.Education:
3.1Communicate identified educational needs to Manager of Internal Care Management or Regional Implementation Coordinator
3.2Maintain a current and comprehensive knowledge of third party payors, insurance reimbursement and the appeal and denial process
3.3Educate staff in cost containment strategies
3.4Explain covered services and resources to Center staff
3.5Instruct Center staff in terminology, language and format that is preferred by Managed Care Operations for reporting.
4.Documentation:
4.1Clearly document all concurrent review and discharge planning information sent to payor
4.2Submit timely, accurate and complete patient and payor information to Managed Care Billing and the Center business office
4.3Forward Monthly Inpatient Tracking Summary and Managed Care Communication Form to Managed Care Billing in a timely manner
4.4Maintain comprehensive case management records on all customers that reflects authorizations, extensions, levels of care, dates of service and rates approved by the payor to include name, phone and date of payor case manager's authorization;
4.5Organize information on Managed Care patients to support easy retrieval of data;
4.6Submit confidential reports as requested by Management.
5.Professional
5.1Promotes the "Network" internally and externally.
5.2Maintain professional image and demeanor.
5.3Comply with all Genesis Health Ventures personnel policies.
5.4Perform other duties as requested





CC01

Qualifications : SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS:
1.Graduate of an accredited School of Nursing with current RN licensure in the state in which employment occurs required. Bachelor's Degree in Nursing preferred. Certified Case Management (CCM) or related clinical certifications also preferred.
2.Five years of recent clinical nursing experience required. Prior experience in utilization review, case management or discharge planning required.
3.Experience in rehabilitation nursing, acute care and/or the insurance field preferred. Two years full time experience in case management which includes service to short/long term facility based clients preferred.
4.Valid driver's license and automobile with appropriate insurance required.

For more information or to apply, Contact:
Paul Krawczynski, Regional Recruiter
paul.k@genesishcc.com
Fax: 610-347-4116

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