Job Description
MUST HAVE A VALID REGISTERED NURSE LICENSE IN NEW JERSEY
Duties:
Provides case management as well as routine discharge planning services to patients and their families, to facilitate safe and timely discharges, to enhance the benefits of medical care, to ensure hospital reimbursement, to provide cost effective acute care and to ensure continuity of care.
Reviews all patient charts within 24 hours of admission to assess appropriateness of admission, intensity of service and potential discharge needs in accordance with the utilization/contractual requirements.
All questionable cases (i.e. inappropriate admission, level of care changes, quality issues) will be communicated to the Attending Physician. If no resolution, CM will refer the cases to the Physician Advisor.
Communicates with insurance providers for admission and continued stay reviews as stipulated by contract in order to certify the patients' stays.
Contacts the Attending Physician to obtain additional clinical information on the case to minimize denials and to assist with reimbursement of care and/or appeals.
Certifies/denies all non-managed care cases on a daily basis. Denied day cases will automatically be referred to the Physician Advisor.
Participants in Interdisciplinary D/C Rounds to concurrently and collaboratively review and facilitate the patient's plan of care. Acts as liaison to assist in identifying opportunities to improve care.
Keeps Director of Social Work abreast of problem areas and seeks guidance in a timely manner.
Effectively coordinates care with ancillary departments and attending physician (i.e. rehabilitation, laboratory, radiology, etc.) to ensure timely provision of care and to decrease length of stay and appropriate treatment and discharge.
EDUCATION + EXPERIENCE REQUIREMENTS:
B.S. in Nursing from an accredited school, college or university.
Active, unrestricted RN licensed in the State of New Jersey. At least two years direct patient care in an acute care hospital. 2 years previous UM/ case management experience preferred.
Critical thinking and strong interpersonal skills.
Ability to work independently and collaboratively in a fast paced environment and to respond to the constant changes evident in the health care setting.
Good organizational and time management skills required. Customer service focus and patient advocacy a must.
Ability to collaborate successfully with professional staff, as well as patients, families and community.
Ability to work with multicultural populations and peer groups. Computer literacy.
Workmen's Comp, NF/MVA and CCM certification a plus.
CREDENTIALS + QUALIFICATIONS:
Knowledge of Utilization Review criteria to include Interqual and/or Milliman.
Knowledge and experience in Medicaid, Medicare, Managed Care Review, communication and documentation requirements.
Knowledge in discharge planning and length of stay initiatives.
Knowledge of home care/discharge planning and referral process.
Job Tags
Contract work,