Care Management Case Manager

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Job Description Summary:

ESSENTIAL JOB FUNCTIONS:

• Obtains or ensures acquisition of appropriate pre-certifications authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party payer guidelines
• Obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements
• Documents, monitors, intervenes/resolves, and reports clinical denials/appeals and supports retrospective payer audit denials; collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor, and third party payers, etc.
• Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory requirements, etc.; serves as an educational resource to all WTH staff regarding utilization review
• Assumes roles in assessment physical, psychosocial, & economic needs for transition of care planning to a variety of levels of care; delegates to others as appropriate
• Documents, verifies, and validates specific data required to monitor and evaluate interventions and outcomes
• Interviews and collects patient specified data and chart review related to readmission and appropriately notifies care team
• Communicates telephonically and electronically with outpatient providers in an effort to enhance the continuum of care
• Integrates performance improvement principles and customer service excellence principles into all aspects of job responsibilities; practice and governmental commercial payer guidelines
• Adheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodies
• Assumes responsibility for WTH required continued education and owns professional growth
• Performs other duties as assigned or required

JOB SPECIFICATIONS:

EDUCATION:

• Bachelor of Science in Nursing preferred.
• Associate or Diploma of Nursing required

LICENSURE, REGISTRATION, CERTIFICATION:

• Current licensure as Registered Nurse in the state of Tennessee.
•  AHA Basic Cardiac Life Support preferred.
• ACM, CCM or other certification applicable to Case Management within 3 years of hire preferred

EXPERIENCE:

• Minimum 3 years of recent acute clinical care experience preferred
• Preferred experience in care facilitation and management and utilization review

KNOWLEDGE, SKILLS AND ABILITIES:

• Strong communication skills
• Ability to develop and maintain positive relationships with customers internal and external to WTH Enterprise
• Care coordination / discharge and transition planning and community resource knowledge preferred

NONDISCRIMINATION NOTICE STATEMENT

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, ethnicity, disability, religion, national origin, gender, gender identity, gender expression, marital status, sexual orientation, age, protected veteran status, or any other characteristic protected by law.