Job detail

Clinical Case Mgr

Riverview Health

#Multidisciplinary Team #Regulatory Compliance #Home Health #Discharge Planning #Person-Centered Approach #Advance Directives #Patient Records #Appeals #Patient Rights

Quick overview

The Clinical Case Manager is responsible for analyzing patient records, managing admission and concurrent reviews to prevent payer denials, and coordinating service approvals with payors within required timeframes. This role involves comparing medical records to care guidelines, communicating with the treatment team regarding length of stay and discharge readiness, and supporting utilization review processes including appeals and peer reviews.

Requirements summary

Candidates must possess a minimum of an Associate Degree in Nursing or a Bachelor's in Social Work, along with at least two years of experience in utilization review and/or discharge planning. A minimum licensure requirement includes being a Registered Nurse, Licensed Social Worker, Clinical Social Worker, or LMSW, depending on educational background.

associate degreebachelor degreepostgraduate degreePatient AdvocacyProblem SolvingRegulatory CompliancePhysician CommunicationDischarge PlanningCultural AwarenessUtilization ReviewCare Plan EvaluationDenial PreventionCollaborative PlanningTransition CoordinationPeer to Peer ReviewsAppeals MonitoringPatient Records AnalysisCare Guidelines ComparisonDischarge Implementation

Job description

Job Responsibilities
Analyze patient records and assume responsibility and accountability for admission and concurrent reviews assuring the prevention of denials from all payers. Assist with notification, submitting clinical information, and coordinates with payors for approval of services within timeframes indicated by each payor.
Compare hospital medical records to established care guidelines and communicates with various members of the multidisciplinary treatment team re expected length of stay, variances, readiness for discharge or transfer to the next appropriate level of care, and optimal recovery course/benchmarks.
Support utilization review in monitoring, reporting and documenting on appeals at all levels, peer to peer reviews and reconsideration, and utilization review metrics.
Communicate with attending and ED physician regarding bed status and level of care criteria. Refer questionable cases to a Physician Advisor for review, following up with attending as indicated.
Coordinate delivery of regulatory documents and may communicate with a discharge planner as needed regarding any changes in bed status.
Research clinical records, appropriate insurance and governmental regulations, accrediting agency standards, and history of the claim to determine next step.
Ensure collaborative planning processes are maximized and informed decisions are made from a person-centered, strengths-based approach; in conjunction with the patient, family and healthcare team, assess and evaluate medical, rehabilitative, psychosocial and physical needs of observation and inpatient admission to ensure appropriate discharge plan are implemented.
Reassess and reevaluate the appropriateness for the plan of care, evaluate progress towards goals, and ensure that the plan is implemented in a timely fashion. Informs team members of current patient status and post discharge care planning process.
Review plan of care and expectations with the patient, family, physician, and healthcare team members. Assist patients in problem solving potential challenges related to the health care system, financial or social barriers.
Discuss all aspects of care planning with sensitivity and cultural awareness.
Coordinate with all agencies involved in the patient’s pre-hospital care as well as those planning for post hospital care, including but not limited to: home health, skilled facilities, LTACH’s, and DME companies.
Provide necessary data to make a referral, provide pertinent information to facilitate transitions of care, schedule post discharge PCP appointments, and follow up with high risk patients post discharge to ensure plan occurred as expected, intervening when required.

Clinical Case Mgr

Quick overview

Requirements summary

Job description

Education Requirements • Minimum

Experience Requirements • Minimum

License/Certification Requirements • Minimum

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