Job ID 2018-11120
The Care Manager is responsible for all activities associated with utilization review. They are also responsible for care coordination for the patients on the area assigned. They work in conjunctionwith other disciplines to address patient needs and plan for discharge. Care management is episodic in this department. Case Managers are responsible for all activities associated with the clinical documentation management program. The Case Manager performs duties and responsibilities in a manner consistent with our mission and values. Principle Accountabilities: % of Time Spent
1. Performs duties associated with utilization review. These duties include admission and concurrent review of patient records to determine appropriateness. Interacting with insurance companies representatives to ensure maximal reimbursement for the Hospital. Communication of information toPatient Accounts for appropriate billing. Assuring appropriate inpatient/outpatient status is assigned. Discusses cases with Attending Physician when documentation does not support continued care atthe current level, and refers cases to Physician Advisor when needed. (30%)
2. Reviews charts and makes daily rounds to assess patient needs and develop strategies toeffectively case manage an assigned patient care area(s). Participates in multidisciplinary care conferences as required. Communicates appropriate information to all parties who participates in the care of the patient. Coordinates care to ensure resources are utilized efficiently. (30%)
3. or each patient who is insured by Medicare, a Severity/Complexity Profile will be maintained. Information on the Profile shall be maintained current, appropriate questions to physicians will be documented and the most appropriate DRG will be assigned. (30%)
4.Supports the Clinical Guidelines Program on area(s) assigned. (5%) 5.Performs other work duties as assigned. (5%) Total 100%
Current licensure as a Registered Nurse in the state of Missouri Required.
Nursing Diploma or Associates in Nursing Required.
BSN or completion of BSN within 5 years of hire date is required.
1. Current Missouri RN licensure required.
2. Five years of hospital based clinical experience or managed care experience preferred.
3. Case Management certification preferred.
4. Capable of utilizing computer hardware and software for the generation of reports.
5. Must be able to work independently and in coordination with various other persons and professions.
6. Has knowledge of hospital operations, personnel roles and community resources.
7. Must have excellent customer relations, communications and organizational skills.
8. Knowledge of DRG assignment, managed care/insurance processes preferred. The assessment, care and treatment provided by the Case Manager will be consistent with the specific age related needs of the patient. The Case Manager is competent to care for patient age groups included on their working area. This may include neonates/infants, children, adolescents, adults and geriatric adults.