CASE MANAGEMENT RN

Job Duties & Responsibilities:

Case Management:

• Conduct preadmission and admission reviews using lnterQual or MCG criteria, collaborating with ED and admitting physicians to determine appropriate hospital level of care.
• Ensure consistency among documentation, criteria (lnterQuaVMCG), and physician orders regarding level of care.
• Partner with admitting physicians to clarify documentation and support accurate status determination.
• Provide ongoing coaching and education with providers on level of care decisions.
• Perform concurrent patient reviews to assess continued appropriateness of status, document progression of care.
• Submit timely updates and clinical information to insurance providers as requested.
• Support peer-to-peer review processes, ensuring required clinical data is readily available.
• Prepare and manage both concurrent and retrospective appeals; communicate status with billing and revenue cycle teams.
• Collaborate with nursing staff to gather patient information and complete documentation accurately.
• Stay informed on Federal and State case management regulations.
• Engage in ongoing education and professional development in care management and Swing Bed standards.
• Facilitate access to specialists and coordinate with interdisciplinary team members.
• Coordinate care transitions and referrals, ensuring communication with primary care and specialty providers.
• Serve as the central point of contact for patients, families, payers, and care teams throughout the care episode.
• Collaborate to develop and implement individualized, safe, and appropriate discharge plans.
• Maintain knowledge of payer coverage for services including Medicare, Medicaid, and private insurance.
• Communicate with care teams daily about discharge plans, patient status, and needs.

Coordinate referrals and obtain authorizations for post-acute services.

• Arrange transportation and follow-up appointments as needed.
• Provide referrals and education on local support services (e.g., housing, food, addiction, caregiver support).
• Report and document suspected abuse, neglect, or exploitation in compliance with policy.
• Assist with discharge paperwork and patient education to ensure a smooth transition from care.

Swing Bed Coordinator:

• Serve as the point of contact for all Swing Bed admissions and care coordination.
• Obtain prior authorization and collaborate with the interdisciplinary team for patients appropriateness and acceptance.
• Coordinate referrals from other facilities and conduct thorough chart reviews.
• Lead interdisciplinary team meetings to establish and update individualized care plans.
• Ensure timely documentation, follow-ups, and care plan modifications as patients progress.
• Maintain compliance with Swing Bed regulations and best practices.
• Attend relevant ICAHN trainings and regional networking events related to Swing Bed and care management.

Position Skills & Qualifications:

Education: Registered Nurse (RN) or Social Worker (SSW/MSW) required.

Experience: Minimum 2 years of clinical experience in acute care, case management, or care coordination. Experience with Swing Bed programs or post-acute care planning highly desirable.

Skills and Abilities:

• Proficient in using lnterQual and MCG criteria.
• Knowledge of payer regulations, utilization review, discharge planning, and care transitions.
• Strong communication, critical thinking, and problem-solving skills.

• Ability to work effectively within a multidisciplinary team.
• Organized, detail-oriented, and capable of managing multiple priorities.
• Proficient with EHR systems and Microsoft 365.

Compliance and Regulatory:

All employees are required to comply with all laws, regulatory guidelines, and health care policies. This includes, but is not limited to federal, state and local laws, applicable State Departments of Health, Healthcare Facilities Accreditation Program (HFAP), Health Insurance Portability and Accountability Act (HIPAA), and LCMH Policies and Procedures. All employees are required to be compliant with hand hygiene guidelines as well as to adhere to safe practices, identify and report unsafe practices.

Other Requirements:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Travel & Telecommuting:

Some travel outside the hospital environment may be required periodically. Some telecommuting and remote work times will be permitted at the approval and coordination with LCMH senior leadership.

Additional Details:

LCMH is an equal employment opportunity employer and is committed to maintaining a workplace that is free of inappropriate or unlawful conduct based on race, color, religion, sex, national origin, age, disability, genetic information, or other protected group status as provided by law.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Salary & Benefits:

• Salary: The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job-related reasons.
• Benefits: Full-time employees are offered a comprehensive benefit package that includes generous PTO, medical, dental, vision, disability, life, accident, and critical illness insurance. Details on benefits are available upon request.

Applicants must be authorized to work for ANY employer in the U.S. We are unable to sponsor or take over sponsorship of an employment Visa at this time.