Case Manager RN-FT in Harlingen, TX at Harlingen Medical Center

Date Posted: 8/11/2019

Job Snapshot

Job Description



Overview

Responsible for the quality and resource management of all patients that are admitted to the facility from the point of their admission and across the continuum of the health care management. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care.  The methodology is designed to facilitate and insure the achievement of quality, clinical and cost effective outcomes and to perform a holistic and comprehensive concurrent review of the medical record for the medical necessity, intensity of service and severity of illness.

 

Responsibilities

Upholds and supports the philosophy, objectives, and policies of the Medical Center.Performs concurrent review in a timely manner utilizing criteria approved by the Utilization Review Committee.  Determines priorities for the order in which patients need to be reviewed.Applies appropriate clinical judgment in the concurrent review process to ensure that information in the medical records meet the criteria for intensity of care level of service for continued hospital stay and/or discharge.Documents all deviations from criteria for continued length of stay and promptly discusses these with the attending physician and/or Medical Director.Communicates daily, as needed, with the Medical Director, or his designee, regarding concurrent reviews and/or difficulties with resource utilization.Participates actively in discharge planning; coordinating appropriate discharge plan based upon the identified needs of the patient and the availability of resources.Functions as the primary liaison with the Medi-Cal field representative and other Medical providers within the hospital; completes TAR’s accurately and timely.Communicates, as requested by insurance carrier, needed information regarding intensity of care and level of service for out of plan patient admissions. Abides with HIPAA regulations.Attends regularly scheduled staff meetings and other educational programs.Assists in the orientation process for new Case Managers.Integrates with various departments in order to enhance patient outcomes.Assists with general office duties, i.e., copying, faxing, mailing, filing, data entry, etc.Interacts with insurance companies and 3rd party payers to obtain authorizations for continued hospital care.Assumes responsibility for the prevention of Medicare, Medi-Cal, HMO and / or other insurance denials.Performs retro reviews, when requested, on patients who have been discharged.Assists in appeal process on any insurance denial.Participates proactively in the goals and objectives of the Case Management Department in reducing medically aberrant LOS, and establishes personal goals to achieve desirable outcomes organizationally.Performs other duties as assigned or required.

Qualifications

Current state Registered Nurse License required.Graduate from a program of nursing required. BSN preferred.Three years acute care nursing experience preferred.  At least one year experience in case management, discharge planning or nursing management, preferred.Current BLS (AHA) certificate upon hire and maintain currentBehavior Violence Prevention Training within 60 days of hire.Knowledge of Milliman Criteria Preferred.

 

We are an Equal Opportunity/Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics.  If you need special accommodation for the application process, please contact Human Resources.  EEO is the Law: http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf