RN, BSN Case Manager – Hospital

Location: Wilmington, DE
Date Posted: 02-01-2018
RN, BSN Case Manager – Hospital
Wilmington, DE
Your Job Summary:
As a member of the medical management team, the RN Case Manager works with patients, family members and outside providers to deliver intensive, comprehensive case management and increase efficient utilization of services, and ensure quality care of the patient while they are being treated at the facility. The Case Manager will be responsible for the management of the patient experience external to the facility and will be the link between the insurance companies and the internal care management process.  The Case Manager also acts as an advocate for patients and their families linking them to other members of the care team to help them gain knowledge of their disease process and to identify community resources for continued growth toward a maximum level of independence.

Your Reward:  
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health.

Your Background: 
Valid, unrestricted state Registered Nurse (R.N.) license and Bachelor of Science in Nursing (BSN) or related field.
Prefer candidates with and/or Certification in Case Management (CCM).
At least 2-3 years of acute care nursing experience required, higher acuity settings (ER/OR/ICU/etc) preferred.
Around 2 years’ experience in case management or utilization review at an acute care hospital or other provider setting.
Ability to asses care needs across populations and plan for care-including transitional care and discharge.
Requires demonstrated experience and competency utilizing InterQual criteria.
Computer literacy (MS Office) and typing skills are necessary.
Must possess the ability to utilize a clinical reasoning process for assessing, planning, implementing and evaluating the plan of care while ensuring that coordination of services are done in a timely manner.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.

Your Duties:
The Case Manager will serve the daily case management needs of patients. This includes administering all provider resources through the care continuum, from the initial referral through discharge and ensuring compliance with the plan of care.  Performs utilization review by applying Milliman Criteria to monitor appropriateness of admissions, level of care, and continued stays, including observation status for all inpatients concurrently and/or retrospectively. They will collaborate effectively with an interdisciplinary team to establish an individualized plan of care for patients.  Initiates and facilitates referrals for home healthcare, infusion therapy hospice, other care facilities, medical equipment and supplies. Assists with transfers to other facilities. They coordinate patient visits with providers and specialists as needed. Completes necessary insurance pre-certifications for all inpatients, surgeries and all outpatient procedures. Continuously monitors email and fax server distribution for incoming pre-cert notifications. Thoroughly documents all communication regarding pre-certification into the electronic record. Takes accountability to ensure all pre-certs are completed to prevent denials of payment. Responsible for writing and tracking insurance appeal letters on denials received from various payers related to medical necessity and precertification issues. The Case Manager will participate in the development of appropriate QI processes, establishing and monitoring indicators. Utilizing their knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms, the Nurse will help guide physicians in their awareness of preferred contracts, providers, and facilities. They will coordinate the approved services with all provider staff under the specific direction of the Medical Director or Manager of Medical Management.
Erik Berg
Search Consultant

CareNational Healthcare Services

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