Case Manager RN 8/16/2016
JOB DESCRIPTIONThe Case Manager RN will Perform pre-certification, certification and/or authorization activities for all requested Home Health Services included as contracted services that meet eligibility and benefits coverage. Responsible for certification determinations and sending written authorizations to referring physician and home health care provider.
DUTIES AND RESPONSIBILITIES:
* Develop coordinated, collaborative care plans with all involved providers.
* Review Home Health admission for clinical appropriateness of the continued care.
* Performs reviews telephonically using the member's medical records, discussion with the member's physician and/or discussion with Home health agency staff.
* Facilitate timely discharges and transfers based on individual needs and care requirements.
* Educate patients to help them understand their health choices and assist them in making informed decisions about their health care.
* Serve as information resource to patients, health care professionals, facilities, health plan representatives, care givers and family members.
* Monitor cost-effective use of resources.
* Refer requests that do not meet coverage guidelines criteria to the Medical Director for a Level III Review.
* Identifies themselves by name, title and company name on all telephone calls. Provides upon request information on specific UM requirements and procedures.
* Answers the telephone and provider and member requests in a timely and polite manner.
* Is responsible for authorizations to be completed within specified time frames in department policy. Proactively escalating those cases that are at risk of not being completed within department policy.
* Uses clinical judgment in authorizations that fall outside of guideline parameters.
* Distributes appropriate authorization letters to providers and members in compliance with department policies and time frames.
* Requests additional information via telephone for referrals that are incomplete and documents request in the member record.
* Consults with CMO if there are questions regarding the case meeting clinical criteria.
* Refers authorized requests to the staffing team to research and secure a home health care provider for the requested and authorized services, in order for the case to be staffed within one business day.
* Documents all member and provider complaints in the appropriate data base and escalates complaints to department supervisor for further action and resolution.
* Maintains and respects confidentiality of member/physician/personnel information
* Responsible for accurate review and entry of authorization data into computerized database.
* Performs all aspects of member care in an environment that optimizes member safety and reduces the likelihood of medical/health care errors.
* Knowledgeable of current Medicare and Medicaid requirements, necessity and justification requirements.
* Maintains a good rapport with physicians, private insurance companies and government agencies.
* Maintains a good working relationship both within the department and with other departments.
* Consults other departments as appropriate to collaborate in member care and performance improvement activities.
* Participates in performance improvement activities for department and CQI activities.
* Accepts additional assignments willingly.
* Completes annual education and licensure requirements.
* Maintains member confidentiality at all times.
* Reports to work on time and as scheduled, completes work within designated time.
* Follows all company policies related to time records.
* Completes in-services in a timely fashion.
* Attends annual review and department in-services, as scheduled.
* Attends at staff meetings as scheduled and reads all staff meeting minutes and other written documents as requested.
* Represents the organization in a positive and professional manner.
* Actively participates in performance improvement and continuous quality improvement (CQI) activities.
* Complies with all organizational policies regarding ethical business practices.
* Communicates and demonstrates the mission, ethics and goals of the facility, as well as the focus statement of the department.
* Registered Nurse; minimum of 5years of experience in a variety of health care settings
* Home health experience preferred
* Current state license in the state where membership lives.
* Ability to read and communicate effectively in English.
* Additional languages preferred.
* Basic computer knowledge such as Word and Excel.
* Excellent customer service and follow-up skills
* Ability to sit for long periods and read monitors.
* Strong attention to detail