Nurse Case Manager

Nurse Case Manager

Requirements

• Current RN license for state in which the nurse practices.
• Three years of clinical nursing experience.
• RNs hired or promoted into this role need to have or obtain their BSN within three years of hire or promotion.

Responsibilities

• Organizes and prioritizes daily work by assessing new, current, and discharging patient needs in area(s) of responsibility. Completes documentation as required.
• Performs utilization review activities to provide patient appropriate, timely, and cost effective care. Coordinates care with patient, care providers, hospital financial services, and third-party payers.
• Maintains an active role in denial prevention. Proactively intervenes with payers to prevent inpatient denials. Performs retroactive reviews on discharged patients as assigned. Communicates any necessary information to payers to help appeal existing denials. Uses level of care criteria to justify the patient’s severity of illness and intensity of service. Reviews payer requirements and government regulations to ensure safe and cost-effective healthcare.
• Screens and coordinates the discharge planning process from patient admission to departure. Assesses patient needs, develops a discharge plan, and coordinates with internal and external services for care during and after the hospital stay.
• Identifies patients with potential avoidable delays, extended stay, readmission, or discharge needs. Coordinates with care providers and leaders to reach optimal solutions.
• Educates, communicates, and coordinates with multiple patient care teams to ensure the patient receives quality care, a timely discharge, and to identify and resolve delays and issues.

Preferred Qualifications

• Bachelor’s degree in Nursing (BSN). Education must be obtained from an accredited institution. Degree will be verified.
• Case management Certification.
• Experience in Case management, Utilization review, and/or discharge planning.