Full-timeEstimated: $55,000 - $74,000 a year
- Documentation review
- Analysis skills
- Acute care
- Conflict management
- Communication skills
Full Job Description
The Point of Entry Case Management Specialist will be responsible for medical necessity review of all scheduled admissions, direct admits, and transfer requests made to the Parkview Health system for admission (excludes L&D, PBH, Ortho Hospital and Rehab/CCC). Uses established screening criteria (InterQual/CMS Inpatient List) to determine appropriate level of care of each requested hospitalization. Provides consultation to physicians and other members of the interdisciplinary healthcare team as needed prior to patient placement. Works collaboratively with Bed Management staff for appropriate bed assignment to achieve positive patient flow. Reviews payer source for potential negative financial liabilities to the patient. Ensures clinical documentation supports medical necessity criteria and meets regulatory requirements, including the admission. Facilitates or verifies appropriate admission order is present in the electronic medical record prior to bed assignment. Communicates admissions/transfers that do not meet medical necessity to the physician advisor (internal or external) and/or the Inpatient Care Transitions leadership team as needed. Actively involved in management of patients in observation status until the decision is made to admit to Inpatient or the patient discharges. Collaborates with ED case management staff to verify patients from all entry points to be reviewed prior to bed assignment.
Must have a BSN from accredited program. Acceptable accrediting agencies are Commission on Collegiate Education in Nursing (CCNE), Accreditation Commission for Education in Nursing (ACEN) or Commission for Nursing Education Accreditation (CNEA).
Valid Indiana Registered Nurse license required. Certification in Case Management is highly desirable.
Required at least 2 years of experience in acute care setting. Preferred experience in Case Management activities. Preferred experience or knowledge of InterQual criteria.
Demonstrates knowledge of DRGs managed care initiatives, payment methods, and statistical analysis. Demonstrates competency at completion of InterQual training program and ongoing inter-reliability testing. Demonstrates understanding of managed care concepts. Demonstrates ability to engage in complex clinical decision-making. Demonstrates a strong commitment to interdisciplinary collaboration and communication. Demonstrates critical thinking, analysis skills and conflict resolution skills. Must have good verbal and written communication skills. Must have excellent people skills and the ability to problem solve efficiently and effectively. Must be available to work flexible hours, including weekends and other times when deemed necessary.
Location: Parkview Health · Case Management
Schedule: Full Time Benefit Eligible, Days, 8a-830p