RN Case Manager (47219)

Under general supervision of the Purchased Referred Care (PRC) Manager, provides utilization review and case management for patients referred for inpatient and outpatient care to other healthcare facilities. Minimizes fragmentation in the healthcare system with a focus in coordinating transitions in care by tracking, monitoring and evaluating referrals and obtaining preauthorization when needed. Uphold the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Maintains regular attendance and punctuality.
• Monitors external referral activities set by PRC, providing quarterly reports to ensure the department is on track to meet necessary measures.
• Provides case management for patients needing referred care from pre-admission to post discharge.
• Works with the patient, family and an interdisciplinary team; develops a care and service delivery plan based on needs of patient, available provider, and financial resources.
• Conducts appropriate concurrent and retrospective reviews on referred care to patients to determine the appropriateness of admission, procedures, and the necessity of continued hospital care.
• Determines medical necessity and appropriateness of level of care using Centers for Medicare & Medicaid Services (CMS) approved criteria for inpatient and outpatient referred care encounters.
• Checks the severity of illness, intensity of service, and discharge criteria on referred patients.
• Refers appropriate cases to the Chief Medical Officer for medical review.
• Screens all referrals for alternate resources and works closely with Business Coordinator and Contract Health Services to maximize the use of alternate resources for referred care payment, protecting PRC funds for those patients who do not qualify for alternate resources.
• Certifies the acute hospital level length of stay for PRC payment and WIHCC utilization purposes.
• Works collaboratively with other departments to coordinate patient needs before discharge, discharge planning activities and continuity of care.
• Determines if services are being delivered as planned and are meeting needs; reassesses, at appropriate intervals, to determine if the patient’s condition or situation has changed, and revises goals and plan of services accordingly.
• Serves as an advocate for the patient and their families.
• Provides in-service training to medical providers/PRC staff to enhance communication.
• Demonstrates ability to build and maintain collaborative relationships with healthcare providers, community organizations, and key stakeholders. Represents the organization at meetings, conferences, and community events to strengthen partnerships and promote organizational initiatives. Position requires occasional travel within the service area and periodic overnight travel for training, conferences, and professional development.
• Requires completion of tasks or duties assigned by a supervisor.
• Upholds all principles of confidentiality and patient care to the fullest extent.
• Adheres to all professional and ethical behavior standards of the healthcare industry.
• Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
• Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
• Possesses cultural awareness and sensitivity.
• Maintains compliance with all Human Resources requirements.
• Performs other duties as assigned.