Coordinator Case Management

Coordinator Case Management

  Not Disclosed

  Philadelphia, PA

  5.0 Months

  Not Disclosed

  Not Disclosed

  Pharmaceutical

Job Description

Coordinator Case Management

Job Summary:

The client is looking for NICU or PICU Case Manager.
The client is looking for a case manager, who has strong discharge planning experience with high tech complicated patients.
Pediatrics preferred and EPIC experience.

Under the general supervision of the Director, the Case Manager provides clinically-based support to the delivery of effective and efficient patient care. Paces each case from physiological and economic perspectives. Has overall accountability for the utilization management and transition management for patients within the assigned caseload. Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement. Uses criteria to confirm medical necessity for admission and continued stay. With the patient, family and health care team, creates a discharge plan appropriate to the patient’s needs and resources

Essential Duties and Responsibilities:

• Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. Documents all case management interventions in the current electronic system (EPIC).

• Validates admission and continuing stay criteria with third party payers as well as the Attending Physicians. Recommends alternative care sites where appropriate.

• Collaborates with third party payers to prevent denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent the denial when possible.

• Supports the effective prevention and management of denials, including providing requested information as part of the appeal process.

• Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual length of stay to initiate a plan for discharge.

• Collaborates and communicates with patients/families related to reimbursement issues and to create a discharge plan. Supports the process of patient choice in establishing a discharge plan.

• Uses clinical knowledge and knowledge of anticipate response to treatment to assess patient progression towards anticipated outcomes. Communicates and coordinates with the patient/family and health care team to intervene when progression is stalled or diverted. Addresses actual/potential barriers to discharge

• Completes the interventions necessary for discharges to home with self-care, home with services or short term skilled nursing facility placement. Assembles necessary referrals, discharge summaries and pertinent information for discharge to home, placement, or transfer prior to the day of discharge.

• Actively contributes to, participates in, and follows through on interventions identified in care coordination and complex patient rounds.

• Identifies high risk patients and creates a collaborative plan to address their unique needs.

Skills

Additional Technical Requirements

• Excellent communication skills and demonstrated organizational skills.

• Ability to work effectively with all departments and all levels of the client professionals.

• Ability to work independently or within a team structure.

• Must be very organized and able to work independently.

• Ability to establish priorities among multiple needs, meet deadlines and maintain standards of productivity.

• Knowledge of managed care admission process (i.e. verification of benefits, admissions notification).

• Ability to effectively negotiate with internal and external providers of patient care services.

• Sound problem solving skills.

• Excellent customer service orientation and strong interpersonal skills.

• Computer skills and a working knowledge of Word, Excel and Access.

Education

Required Licenses, Certifications, Registrations

RN license in the state of Pennsylvania

Required Education and Experience

Required Education: Nursing Diploma

Required Experience: Five (5) years’ experience.

Preferred Education, Experience & Cert/Lic

Preferred Education: BSN

Preferred Experience: Previous experience with discharge planning or home care experience.

Prior experience as a Case Manager or Utilization Reviewer.

Previous experience in a pediatric setting or similar adult setting

Preferred Licenses/certificates/registrations: CCM or ACM Certifications

Skills and Experience

The Skills and Experience match parameters for the candidate are parsed from the uploaded Job Description.

Required Skills

REGISTERED NURSECASE MANAGEMENTPROBLEM SOLVINGCUSTOMER SERVICEVERY ORGANIZED

level 3 - COVID Vaccine required
VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.