Case Manager RN WellMed Parkdale

The Case Manager II - Inpatient Services performs onsite review or telephonic clinical review of inpatient admissions in an acute hospital, rehabilitation facility, LTAC or skilled nursing facility. Actively implements a plan of care utilizing approved clinical guidelines to transition and provide continuity of care for members to an appropriate lower level of care in collaboration with the hospitals/physician team, acute or skilled facility staff, ambulatory care team, and the member and/or family/caregiver. The case manager is responsible for coordinating the care from admission through discharge. The Case Manager participates in Patient Care Conferences to review clinical status, update/finalize transition discharge needs, and identify members at risk for readmission.

Primary Responsibilities

• Independently collaborates effectively with Interdisciplinary care team (ICT) to establish an individualized transition plan for members
• Independently serves as the clinical liaison with hospital, clinical and administrative staff as well as performs a review for clinical authorizations for inpatient care utilizing evidenced-based criteria within our documentation system
• Performs expedited, standard, concurrent, and retrospective onsite or telephonic clinical reviews at in network and/or out of network facilities. The Case Manager documents medical necessity and appropriate level of care utilizing national recognized clinical guidelines for all authorizations
• Interacts and effectively communicates with facility staff, members and their families and/or designated representative to assess discharge needs, formulate discharge plan and provide health plan benefit information
• Identifies member's level of risk by utilizing the Population Stratification tools and communicates during transition process the member's transition discharge plan with the ICT
• Conducts a transition discharge assessment onsite and/or telephonically to identify member needs at time of transition to a lower level of care
• Manages assigned case load in an efficient and effective manner utilizing time management skills
• Demonstrates exemplary knowledge of utilization management and care coordination processes as a foundation for transition planning activities
• Independently confers with UM Medical Directors and/ or Market Medical Directors on a regular basis regarding inpatient cases and participates in department huddles
• Enters timely and accurate documentation into designated care management applications to comply with documentation requirements and achieve audit scores of 90% or better on a monthly basis
• Adheres to organizational and departmental policies and procedures
• Takes on-call assignment as directed
• The Case Manager will also maintain current licensure to work in State of employment and maintain hospital credentialing as indicated
• Decision-making is based on regulatory requirements, policy and procedures and current clinical guidelines
• Maintains current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms
• Refers cases to UM Medical Director as appropriate for review for cases not meeting medical necessity criteria or for complex case situations
• Monitors for any quality concerns regarding member care and reports as per policy and procedure
• Performs all other related duties as assigned

Required Qualifications

• Bachelor's degree in Nursing and/or, Associate's degree in Nursing combined with 4+ years of experience above the required years of experience
• Current, unrestricted RN license specific to the state of employment
• Case Management Certification (CCM) or ability to obtain CCM within 12 months after the first year of employment.
• 4+ years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions
• 3+ years of managed care and/ or case management experience
• Knowledge of utilization management, quality improvement, and discharge planning
• Knowledgeable in Microsoft Office applications including Outlook, Word, and Excel
• Proven ability to read, analyze and interpret information in medical records, and health plan documents
• Proven ability to problem solve and identify community resources
• Proven planning, organizing, conflict resolution, negotiating and interpersonal skills
• Proven ability to utilize critical thinking skills, nursing judgement, and decision making skills
• Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously
• Proven ability to be in a stationary position or move for prolonged periods
• Reliable transportation and Case Manager is responsible for maintaining an active driver's license

Preferred Qualifications

• Experience working with psychiatric and geriatric patient populations
• Bilingual (English/Spanish) language proficiency

Physical & Mental Requirements

• Ability to lift up to 25 pounds
• Ability to push or pull heavy objects using up to 10 pounds of force
• Ability to sit for extended periods of time
• Ability to stand for extended periods of time
• Ability to use fine motor skills to operate office equipment and/or machinery
• Ability to receive and comprehend instructions verbally and/or in writing
• Ability to use logical reasoning for simple and complex problem solving

The salary for this role will range from $60,200 to $107,400 annually based on full-time employment.