Job Description

Assist Director of Case Management with the general operations of Precertification, Case Management and Social Services as well as other functions as assigned.

Provides Leadership sets goals and establishes priorities for Utilization Review/ Case Management Staff for department efficiency.

Works with medical staff, service line administration, hospital and alternative case team to develop process to improve case, reduce costs, increase efficiency and achieve optimal outcomes.

Interacts and collaborates with physicians and their office staff, members of the healthcare team, review entities, third party payers, peer review organizations, the patient/family and other case managers throughout the healthcare continuum and acts as the patient advocate.

Coordinates care thrpugh assessing, planning, monitoring, implementing and evaluating delivery of services using an integrated approach and appropriate resources; standard operating procedures; and case management principles to enhance quality and effectiveness of care delivered.

Assures verification of benefits, eligibility, and pre-authorization of services and performs continued stay reviews.

Provides education/consultation to the health care delivery team/patients/families about care options, community resources, local, state and federal laws/regulations, standards of accrediting agencies, insurance benefits, cost factors and any information that assists patients with making informed decisions.

Utilizes payer choice criteria to determine appropriateness of assigned level of care by reviewing the medical record, physician discussion, plan of care, assessing patient/family needs, discharge planning needs and to facilitate level of care transitions.

Participates in QI /PI activities and identifies and reports issues for improvement.

Communicates and utilizes policies that assure patient’s fundamental right to considerate care, protects their personal dignity and respects their cultural, psychosocial and spiritual values in an effort to meet patient’s care needs and preferences.

Assume responsibility for personal growth and development by attendance and/or participation in in-services and continuing education programs.

Performs other duties as assigned while supporting the hospital mission, vision and values to enhance quality, utilization, service delivery and customer satisfaction.

Actively participates in promotion of Service First activities and goal achievement.

Participate in meetings/conferences etc. as appropriate, attend in services and then teaches staff. Implements and monitors new policies, procedures and regulations.

Coordinate operations of the Precert, Case Managers and Social Workers including monitoring productivity. Assist with staff meetings and provide educational opportunities.

At least three (3) years clinical experience in medical/surgical, critical care or ER. Two (2) years of quality/utilization management or case management experience preferred or equivalent. Basic computer skills preferred.

Current state licensure as RN. Case Management certification preferred.