The case manager is responsible to assist in the development, planning, coordination and administration of the activities of utilization review. Conduct initial and concurrent review of the medical record to determine appropriateness and medical necessity of admission, continued hospital stay and use of ancillary services. Assumes a leadership role within the interdisciplinary team to coordinate services through the continuum of care to achieve optimal clinical and resource outcomes.
Interviews patients and families to assess for discharge needs
Screens for High Risk Patients and manages to that.
Performs Utilization function in accordance with InterQual standards, medicare regulations and payor contracts.
This includes admission and concurrent reviews, seeking authorizations from payers as appropriate and referring cases to the Physician Advisor.
Communicates determinations to all stakeholders.
Argues denials assertively. Completes peer to peer paperwork for the Physician Advisor.
Utilizes Case Management software to document UM process as well as discharge process.
Tracks avoidable days, denials and post acute services including DME via Case Management software.
Identifies barriers to treatment and can initiate a plan that supports optimal quality, cost and patient satisfaction.
Current RN License in the state of PA.
RN from Accredited School of Nursing/Associate degree or Bachelor's Degree