- Registered Nurse, in good standing
- Graduate of an NLN or CCNE accredited nursing program strongly preferred
- BSN preferred
- Minimum 2 years clinical nursing experience required
- 1+ years of supervisory/decision making experience strongly preferred
- 2+ years Case Management and/or Utilization Management experience strongly preferred
- Certification in Case Management (CCM or ACMA) preferred
- Current BLS required
- Fluent in English, both written and oral
- Commitment to the highest ideals of the nursing profession in caring for patients
- Collaborative teamwork skills within an interdisciplinary group focused on patient care
Knowledge, Skills and Abilities
- Able to prioritize and execute tasks in a high-pressure environment, short timelines, among multiple priorities
- Excellent understanding of the company goals and objectives
- Highly self-motivated and directed, with keen attention to detail
- Proven analytical and creative problem-solving abilities
- Strong customer service and support philosophy
- Ability to work with all levels of staff to define business requirements and goals, and to identify and resolve issues
- Ability to foster effective relationships and build consensus through the all levels of leadership in the organization
- Ability to work independently
- Ability to provide remote leadership & guidance to hospitals
- Ability to work with multiple forms of technology on a consistent basis
- Ability to exercise independent judgment
- Exhibits strong decision-making skills
- Displays excellent communication skills
- Ability to document accurately and concisely
- Conducts and documents admission and continued stay reviews in Case Management database software.
- Utilizes hospital approved medical necessity guidelines (such as InterQual or Milliman) for all inpatient or observation service reviews, identifying Severity of Illness (SI) and Intensity of Service (IS) criteria to determine appropriate level of care and admission and continued stay appropriateness. Documents appropriate medical necessity criteria in Case Management database software.
- Conducts medical necessity reviews based on established criteria and completes all payer notifications. Documents this information in Case Management database software using specific indicators and criteria as approved by medical staff, DNV, CMS, and other state agencies.
- Completes face to face assessment of patients and family needs at time of admission.
- Acts as patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery.
- Conducts and documents patient assessment related to quality and clinical risk factors.
- Reports variances and delays in the plan of care and communicates with appropriate health care team members.
- Documents variances and delays in Case Management database for each occurrence.
- Coordinates the integration of Social Services/Case Management functions into the patient care, discharge, and home planning processes with other hospital departments, external service organizations, agencies and healthcare facilities.
- Refers cases where patients and/or family would benefit from intervention required to complete complex discharge plan to Social Worker.
- Mobilizes resources and interviews, as needed, to achieve expected goal to assist in achieving desired clinical outcomes within the desired timeframe.
- Conducts review for appropriate utilization of services from admission through discharge. Evaluates patient satisfaction and quality of care provided.
- Initiates and presents “denial letters” and/or “lack of authorization potential denial letters” as appropriate.
- Assesses patient care required throughout continuum of care for diagnosis, procedures and plan of care as appropriate.
- Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assist physicians to maintain appropriate cost and progression towards desired patient outcomes.
- Collaborates with clinical staff in the development and execution of the plan of care and achievement of patient goals.
- Conducts and documents continued stay reviews for patients using approved criteria. Review reflects medical necessity of ongoing treatments that require continued stay versus lower level of care, physician’s rationale for keeping patient when applicable, and physician’s plan of care.
- Conducts reviews and documents appropriate medical necessity criteria to support observation to inpatient conversion in the Case Management database software.
- Notifies Patient Access Coordinators/Managers about all conversions of patient’s admission level of care (observation service to inpatient or inpatient to observation service).
- Documentation on all new admissions reflects awareness of high risk issues when applicable. (Palliative care, Domestic Violence concerns, CAGE assessment indicating alcohol/drug problem and readmissions).
- Monitors diabetic patients for recent HgbA1C value. If elevated, makes appropriate Diabetic Care Center referral.
- Monitors patient information regarding charges, length of stay (LOS) and outliers.
- Coordinates the provision of social services to patients, families and significant others
- Records pertinent data in Case Management database concerning denials, delays, avoided delays and cost avoidance interventions.
- Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals.
- Demonstrates self-directed learning and participates in continuing education to meet own professional development.
- Serves as a resource for other health care members and keeps market leadership notified of potential legal risk issues.
- Conducts discharge planning assessments on identified patients that are consistent and provide for continuity of care for the patient. Collaborates with Social Worker as necessary.
- HICS (Incident Command training- introductory online basic course)
- Performs prior authorization process by performing clinical review of requests requiring medical review and entering authorizations into the system.
- Resolves all authorization requests in a timely manner based on the type of authorization request and according to the policy and procedure.
- Refers cases to the site Medical Director or designee when the treatment request does not meet medical necessity guidelines or when a peer to peer conversation is necessary to establish appropriateness.
- Communicates the outcome of authorization requests with the provider and contacts the provider to obtain additional clinical documentation as needed or requested.
- Assists with the development and generation of member specific denial letters with concise rationale for the denial and reference to the exact guideline supporting the denial.
- Demonstrates basic knowledge of medical terminology, ICD-10 and CPT codes as required for role.
This is a telecommute position. Will predominately work remotely from home.
If you are applying for a position in the U.S., you must be at least 18 years of age, legally authorized to work in the U.S., and not require sponsorship for employment visa status (e.g. TN, H1B status), now or in the future.
THP strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. THP is proud to be an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national origin, age, disability, Veteran status, gender identity or expression, genetic information or any other legally protected status. We maintain a drug-free workplace and perform pre-employment substance abuse testing.
The essential functions listed are typical examples of work performed by positions in this job description and are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks and responsibilities. Specific duties and responsibilities may vary depending on department or program needs without changing the general nature and scope of the job or level of responsibility. Employees may also perform other duties as assigned.