Case Manager

Case Manager

GENERAL SUMMARY

The Case Manager is responsible for coordinating the case management care plan to meet the individual / caregiver needs, promoting quality, and cost-effective outcomes. This position involves identifying and resolving barriers that may hinder effective patient care and patient progression to a safe discharge in a timely manner. The Case Manager is responsible for the facilitation of clinically pertinent reviews on patient admissions for continued stay reviews including completion of certifications. Reports to department leadership.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Educates and empowers individual / caregiver toward self-care and independence.

Collaboratively works to carry out the process of assessment, planning, facilitation, care coordination, evaluation and advocacy options and services to meet the individual’s and family’s comprehensive health needs.

Assesses the patient’s plan of care and develops, implements, monitors, and documents the utilization of resources and progress of the patient through their care.

Interfaces with managed care organizations, external reviewers, and other payers to ensure that the admission and continued stay standards are in compliance with Centers for Medicare and Medicaid Services (CMS) standards.

Facilitates options and services to meet the patient’s health care needs.

Performs all other duties as assigned.

LICENSES AND / OR CERTIFICATIONS

Preferred Licenses and / or Certifications

Registered Nursing License in the State of Virginia or Registered Nurse (RN) holding a valid Compact State license preferred.

Case Management Certification preferred.

MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS

Required Education and Experience

Registered Nursing License in the State of Virginia, Registered Nurse (RN) holding a valid Compact State license or Master of Social Work (MSW) from an accredited college / university required.

Three years or more acute care experience required.

Must provide record of all licensures, certifications, training, and educational requirements at the time of hire.

Continuous re-certification and / or maintenance of state licensures, certifications, training, educational and application requirements is required during employment.

Preferred Education and Experience

Bachelor of Science in Nursing (BSN) preferred.

Must provide record of a completed degree or academic transcript from an accredited program, college, or university at time of hire.

One year or more case management / care coordination experience preferred.

Three years of acute care experience in pediatric field preferred.

Required Knowledge, Skills, and Abilities

Professional knowledge of area of responsibility to direct planning and implementation of individualized service plan for eligible children with special health care needs to include medical care, social, developmental, educational, vocational, and financial aspects.

Possess the ability to plan, manage and establish a professional working environment within areas of responsibility.

Capable of identifying problems and implementing solutions for operational and organizational issues.

Demonstrates an understanding of the authorization process with Medicaid and other insurances as well as knowledge of Medicaid regulations.

Highly motivated, enthusiastic team player who takes initiative.

Strong organizational skills with attention to detail and commitment to accuracy.

Possess strong verbal and written to adequately describe patient’s clinical presentation and progress in a comprehensive and concise manner.

Strong interpersonal skills as well as, the ability to interact with and build collegial relationships with diverse individuals.

Proficiency and technical aptitude with the use of Adobe Acrobat and MS Office products, including Excel, PowerPoint, Outlook, and Word.

Preferred Knowledge, Skills, and Abilities

Knowledge of utilization review and hospital finance processes preferred.

WORKING CONDITIONS

Normal office environment with little exposure to excessive noise, dust, temperature and the like.

PHYSICAL REQUIREMENTS

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