Case Manager-1

Essential Functions

• Perform admission and continued stay reviews of all inpatients and outpatient/observation patients in a bed; at times, this may be retrospective.
• Perform precertification on procedures ordered while patients are hospitalized.
• Issue required Medicare/Medicaid notifications of medical necessity changes to patients while hospitalized.
• Issue notifications of non-coverage letters to patients if received during hospital stay.
• Document clear billing notes into the EMR payer communications navigator to avoid billing denials.
• Perform medical necessity denial appeals.
• Maintain a close, collaborative relationship with the medical staff to promote continuity of care and avoid delays in service.
• Must demonstrate basic knowledge of discharge planning needs

• None

Qualifications

• Associates degree in Nursing
• Current RN license in the state

• Bachelor's degree or higher in Nursing

• Two (2) years acute care experience
• Must pass Blue Cross Blue Shield Iterator Reliability Test with 90% within six (6) months of hire

• Three (3) years acute care experience
• One (1) year utilization review experience

• Demonstrates advanced computer skills (ability to generate reports, graph trends).
• Clinical knowledge and experience in the care of patients with multiple and complex diagnoses, disease process, and care needs.
• Ability to prioritize work and meet deadlines.
• Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge.
• Ability to develop leadership skills and to serve as a role model for clinical staff.
• Ability to lead and actively participate in multidisciplinary teams.
• Ability to work independently within a team structure.