Case Management services are generally focused on members who fall into one or more high risk or high cost groups and require significant clinical judgment, independent analysis, critical-thinking, detailed knowledge of departmental procedures, clinical guidelines, community resources, contracting and community standards of care. Case Management includes assessment, coordination, planning, monitoring and evaluation of multiple environments. Must be licensed RN/LPN in the Commonwealth of Virginia.
1. Coordinates the integration of social services/case management functions into the patient care, discharge and home planning processes with other departments, external service organizations, agencies and healthcare facilities.
2. Conducts concurrent medical record review using specific indicators and criteria as approved by medical staff.
3. Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in achieving desired clinical outcomes within specific time frame.
4. Conducts review for appropriate utilization of services from admission through discharge. Evaluates patient satisfaction and quality of care provided.
5. Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assists physicians in maintaining appropriate cost, case and desired patient outcomes.
6. Responsible for the coordination of health care decisions by using a systematic approach to assure treatment plans that improve quality and outcomes.
7. Working with the complex care needs.
- Licensed RN or LPN with 2 years case management experience.
- Experience in insurance-based case management REQUIRED. Previous computer experience, particularly with the use of Microsoft Office is required.
Thorough knowledge of case management principles, healthcare management and reimbursement.
Knowledge of CMS guidelines and experience working with payor specific guidelines and contractual rules preferred.
Customer service abilities including effective listening skills.
Critical thinking skills, decisive judgment and the ability to work with minimal supervision meeting firm deadlines.
Assertive and persuasive communication skills (written and verbal), action oriented.
Ability to convey medical terms and treatment plans so they are understood by patients and their caregivers.
Excellent organizational, record keeping, and time management skills.
Astute problem-solving skills with the ability to multi-task.
Compassionate and empathetic demeanor with the ability to work both independently and in a group/team environment.