Top Reasons To Work At AdventHealth South Overland Park
Received Magnet® recognition from the American Nurses Credentialing Center in January 2019
Providing faith-based, whole person care to Kansas City since 1962
Excellent health benefits, an onsite child care center and fitness facility
Tuition reimbursement to support continuing education
Employee Referral Program
Largest health care provider in Johnson County with three campuses
Full Time, Days
You Will Be Responsible For:
Effectively functions as part of a self-directed work team
Coordinates the integration of utilization management, care coordination and discharge planning functions for patient care to meet established level of care, length of stay goals and patient needs, complying with all associated regulatory requirements and policies
Mobilizes resources to achieve expected goals per the patient’s plan of care and ensures that patient diagnostics are appropriate and necessary and completed with the established timeframe
Anticipates discharge planning needs; refers discharge planning and psychosocial needs to Social Worker and/or Case Management Assistant. Facilitates coordination of services
Leads multidisciplinary team meetings for review of the patient’s plan of care, utilization management and discharge planning, collaborating with team members to address patient needs and desired outcomes
Coordinates the care of patients: Works collaboratively with the multidisciplinary team and ancillary departments to move patients efficiently through the continuum, optimizing positive patient outcomes
Assumes final accountability to ensure that care of the patient is appropriately coordinated to meet clinical and transitional needs at time of discharge
Communicates timely and effectively with third party payers regarding certification and discharge needs
Effectively completes or delegates tasks related to delivery of the 2nd IM, Home Health Referrals, acquiring and tracking the Face-to-Face Evaluation, arrangements for home medical equipment, and assistance with purchase of medications and any other appropriate actions to aid in the execution of the discharge plan.
Maintains confidentiality of patient and business information
Identifies and manages risks, resolves issues as they arise; reports and documents adverse events and reportable conditions
Documents appropriately and timely in Cerner Care Manager and CPA as applicable
Assesses and refers appropriate cases to the Physician Advisor for review
Conducts initial, concurrent, and retro reviews as necessary for department productivity. Conducts utilization review with external review agency representatives as required
Assesses appropriate level of service of assigned patients. Informs and assists physicians to ensure appropriate documentation exists to support assigned level
Maintains knowledge and application of Evidence Based Criteria. Able to identify and apply correct criteria to determine medical necessity and level of care
Demonstrates knowledge of regulatory guidelines and requirements for utilization management and discharge planning assessment as indicated by TJC, CMS, KePRO and other agencies
Demonstrates proficiency in use of the electronic medical record and programs specific to the role
Cooperates with changes in staffing schedules and workload in order to achieve department productivity standard. Rotate holiday and weekend on-site coverage as assigned
Participates in Performance Improvement activities
Incorporates patient, physician, customer needs and concerns into decision-making and organizational action.
Evaluates patient satisfaction and intervenes/acquires resources to ensure patient and family needs are met.
Serves as patient advocate and enhances a collaborative relationship between the physician and multidisciplinary team with the patient and family to maximize informed decisions
Review patient medical record for over, under, and inappropriate utilization. Review for justification of patient admission and continued stay. Conducts timely and accurate interventions and follow-through
Informs Patient Financial Services and Social Worker of patients in needing financial counseling
Tracks and documents avoidable days; proactively intervenes when appropriate and/or warranted
Utilizes criteria for referring patients for long stay reviews and make referrals as indicated
Proactively manages and/or assists with addressing denials
Assists in training new hires.
As assigned Denials Management:
Demonstrates understanding and proficiency in the management of denials and appeals.
Completes appeals, demonstrating professional and effective communication- written or verbal.
Respond to Work items within a timely fashion and is detailed with response in Cerner and CPA
Track and trend denials making system improvements which may include working with a sub group or committee.
Provides feedback to staff and other departments as necessary regarding the trending of any issues identified and collaboratively works to develop action plans to improve the processes
Creates and reports relevant accurate, and timely reports concerning denials and appeals using spreadsheets, data and graphs as needed to applicable committees or leadership.
What You Will Need:
Associates Degree in Nursing Required; BSN strongly preferred
2 year minimum of position related experience in an Acute Medical Hospital setting within the last 3 years or 2 years minimum of Care Management experience within an insurance company setting
RN license in Kansas required
Certified Case Manager (ACAM or CMA) preferred
The Case Manager provides expertise for enhancing the quality of patient management and satisfaction, continuity of care and cost-effective practice through effective and timely care coordination. The Case Manager has accountability for care coordination, utilization review and discharge planning assessment. The Case Manager performs varied duties relating to utilization management both concurrently and retrospectively, incorporating knowledge of hospital policies/procedures /protocols, state and federal regulations, and utilization criteria as established by the medical staff, and nursing/health care knowledge. They communicate findings to appropriate parties as indicated to facilitate the utilization review process or quality improvement initiatives related to utilization management (e.g. external review organizations, medical/organizational departments or committees). Additionally, performs care coordination and discharge planning functions related to moving the patient efficiently through the continuum of care, focusing on minimizing system barriers for timely and safe patient discharge to the next appropriate level of care. The Case Manager assesses readmissions and assists the quality management process in identifying trends and establishing plans of correction where appropriate.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.
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