Internal Case Manager

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Position Description:

POSITION SUMMARY: Responsible for the promotion of quality, cost-effective services and care through a collaborative process that coordinates, monitors, and evaluates services accorded to all transitional patients admitted to the assigned Genesis ElderCare Center.RESPONSIBILITIES/ACCOUNTABILITIES:1. Financial Role:1.1 Provide current, accurate and complete clinical information to payor1.2 Be familiar with third party reimbursement, insurance coverage and contract requirements1.3 Communicate financial and statistical information to Genesis ElderCare Center, Business Office and Managed Care Billing 1.4 Negotiate for appropriate continuation of length of stay or extension of services and appropriate Level of Care rates1.5 Assess available resources to optimize resource utilization1.6 Facilitate obtaining payor authorization for recommended treatments, procedures, supplies, equipment and excluded medications1.7 Assist in identifying alternatives/solutions to uncovered services1.8 Assist Center in responding to denial of payment by providing clinical information that substantiates the need for continued coverage.2. Resource Management:2.1 Assess patient/family risk factors as it relates to resource utilization: chronicity, complications and comorbidity and identify barriers to a timely discharge2.2 Act as resource to physicians, NPs and Treatment Team to identify alternate, cost-effective treatment options2.3 Review Pre-Placement Assessments to identify costly treatments, supplies or services and assist staff in obtaining authorizations2.4 Identify overuse or resources such as rehabilitation therapy, diagnostic studies, nonformulary medications and medical supplies2.5 Review Admission orders on all managed care patients for appropriateness and notify responsible personnel when duplicate services are ordered2.6 Verify that the “Care Management Client” form is correct for contracted vendors to be used for needed patient services2.7 Clearly communicate contract inclusions and exclusions to Treatment Team as necessary2.8 Utilize standard review forms and language for Treatment Team documentation to comply with payor requirements2.9 Maintain and submit utilization data/information/reports as requested by Managed Care Operations or the Manager of Internal Care Management2.10 Advise Center of changes in reimbursement mechanisms2.11 Identify practice patterns within the Center that contribute to high resource utilization and report to Manager of Internal Care Management2.12 Monitor changes in status that could lead to hospital readmission and report to nursing2.13 Develop and implement discharge plan to include responsibilities of nursing, rehab and social service staff and communicate plan to payor, staff and customer/family as necessary2.14 Consult Social Worker immediately for all identified social, customer/family problems that are identified as barriers to a timely, appropriate discharge.3. Education:3.1 Communicate identified educational needs to Manager of Internal Care Management or Regional Implementation Coordinator3.2 Maintain a current and comprehensive knowledge of third party payors, insurance reimbursement and the appeal and denial process3.3 Educate staff in cost containment strategies3.4 Explain covered services and resources to Center staff3.5 Instruct Center staff in terminology, language and format that is preferred by Managed Care Operations for reporting.4. Documentation:4.1 Clearly document all concurrent review and discharge planning information sent to payor4.2 Submit timely, accurate and complete patient and payor information to Managed Care Billing and the Center business office4.3 Forward Monthly Inpatient Tracking Summary and Managed Care Communication Form to Managed Care Billing in a timely manner4.4 Maintain comprehensive case management records on all customers that reflects authorizations, extensions, levels of care, dates of service and rates approved by the payor to include name, phone and date of payor case manager’s authorization;4.5 Organize information on Managed Care patients to support easy retrieval of data;4.6 Submit confidential reports as requested by Management.5. Professional5.1 Promotes the “Network” internally and externally.5.2 Maintain professional image and demeanor.5.3 Comply with all Genesis Health Ventures personnel policies.5.4 Perform other duties as requested

Qualifications:

SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS:1. Graduate of an accredited School of Nursing with current RN licensure in the state in which employment occurs required. Bachelor’s Degree in Nursing preferred. Certified Case Management (CCM) or related clinical certifications also preferred.2. Five years of recent clinical nursing experience required. Prior experience in utilization review, case management or discharge planning required.3. Experience in rehabilitation nursing, acute care and/or the insurance field preferred. Two years full time experience in case management which includes service to short/long term facility based clients preferred.4. Valid driver’s license and automobile with appropriate insurance required.