Under the supervision of the Manager, the Case Manager (CM) has knowledge and skill in the areas of discharge planning, transitions of care, utilization management (UM), medical necessity, and patient status determination. The CM facilitates effective processes based on the regulatory and reimbursement requirements of various commercial and governmental payers. The CM assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. They provide cost-effective services while maintaining quality care through collaboration with health care providers to coordinate the transition of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement. The CM performing utilization management (UM) provides the critical function of obtaining certification and approval of the patient's hospital stay as required by the payer.
- Graduate of an accredited school of nursing, Bachelor's Degree (other than nursing) with an ADN or an accredited school of Social Work (MSW)
- 3-5 years healthcare experience or 1-3 years Case Management experience (Care Coordination, Transitions of Care or Utilization Management)
- Current R.N. licensure in the state of SC or Current Social Work licensure in the state of SC
- BSN, MSW
- 3-5 years
- RN, LMSW
Core Job Responsibilities
- Complies with established policies and procedures
- Complies with regulatory requirements of utilization review and discharge planning
- Responsible for assessment and reassessment of patients' physical, social, emotional and financial needs.
- Develops a comprehensive patient centered discharge plan, incorporating the patient goal into the discharge plan
- Communicates with the patient/family/care-giver and interdisciplinary patient care team to facilitate patient care, development of a comprehensive patient centered discharge plan and utilization review functions
- Negotiates timely decisions to expedite the discharge plan and ensure seamless transitions across the continuum of care
- Documents clearly and concisely all contacts and information of the patient's case management process in the medical record
- Responsible for the core functions of the Utilization Management Plan
- Performs initial and subsequent utilization reviews utilizing criteria.
- With utilization review, obtains certification on admissions and continued certification by providing clinical information to the payer or to review companies designated by the patient's payer. Monitor and secures final certification up to and after patient discharge until resolved. Assists with management of incoming faxed communications
- With utilization review, assists with initial denial, peer to peer information, status determination and/or appeal process and communicates necessary information to the physician advisor, CM manager, denials team manager and/or QIO as required
- Uses communication tools to ensure that information is collected, reviewed, escalated if needed and disseminated appropriately for all commercial, managed care and government plans.
- Communicates updated insurance information to the centralized referral center if insurance information provided is not accurate
- Performs timely data entry of information when results are received including covered, denied and avoidable days.
- Complies with delivery of regulatory notices - Important Message, Medicare Outpatient Observation Notice, Detailed Notice of Discharge and Hospital Issued Notices of Non-Coverage.
- Plans effectively in order to meet patient needs, manage length of stay and promote efficient utilization of resources.
- Provides cost-effective services through resource management and facilitating throughput while maintaining quality care and meeting customer service needs by collaborating with healthcare providers to coordinate care delivery
- Provides patient/family/caregiver with quality data-based information on post-acute providers to facilitate referrals to meet the care transition needs of the patient
- Utilizes a secure electronic platform to communicate with post-acute providers and payers
- Completes required education and ongoing competencies as assigned
- Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations
- Other duties as assigned
Additional InformationSpartanburg Regional is an integrated healthcare system that provides care from birth to hospice. As a a partner with the community for 90 years, we have earned a reputation for technological excellence. With more than 5,600 employees, Spartanburg Regional prides itself in being one of the most recognized healthcare facilities in Upstate South Carolina. A long list of accolades and accomplishments keep our employees proud. We believe the pride and quality in our organization is the result of a focused effort of our staff and resources.
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