Comprehensively plans for case management services for a targeted patient population. Carries out activities related to utilization management, discharge planning, care coordination and referral to other levels of care. Works with physician, Social Worker and interdisciplinary team to facilitate clinical pathways and achievement of desired treatment outcomes. Promotes interdisciplinary collaboration and champions service excellence. Works collaboratively to ensure patient needs are met and care delivery is coordinated across the continuum at the appropriate level of care.
Area of Specialization: RN Clinical Audit and Denial Care Manager:
Responsible for the management of clinical audits and denials related to inpatient medical necessity and/or level of care, and coding. Reviews patient medical records and all other pertinent patient information, and applies clinical and regulatory knowledge, screening criteria and judgment, as well as knowledge of payor requirements and denial reason codes/rationale, to determine why cases are denied and whether an appeal is required. For all inappropriate denials, relevant information is submitted, according to each payors appeal timeframes, through denial management tracking software with a bi-directional interface with physician advisor for appeal coordination and follow-up.
1. Serves as liaison and point of contact for audits, clinical denials, and appeal inquiries.
2. Continually stretches oneself and expands comfort zone, not only for personal development but also for the betterment of the department in cross-training of employees.
3. Enters required canned text in MEDITECH from the: (a) point of assignment for clinical review
by PFS, (b) appeal process, and (c) clinical review completion resulting with final appeal
4. Proactively shares knowledge, processes, and procedures within the team in the cross-training effort.
5. Maintains current knowledge base for regulations and appeal timeframes: state, federal, and
6. Communicates with multiple levels, in and out, of the organization (e.g. managers, physicians,
clinical and support staff, and payors) to positively affect clinical and financial outcomes, in a
7. Identifies and resolves difficulties in a timely manner or brings them to the attention of
management, gathers and analyzes information skillfully and efficiently, develops alternative
solutions, and uses reason even when dealing with emotional topics.
8. Demonstrates accuracy and thoroughness, is highly detail-oriented, looks for ways to improve
and promote quality, applies feedback to improve performance, and monitors own work to
9. Conveys issues and barriers to manager for resolution.
10. Informs release of information vendor about missing or insufficient medical record
11. Performs clinical quality check on medical records for completion prior to submission to audit
12. Will perform and maintain the standard essential functions of the RN Case Manager related to
taking call and working holidays, as needed.
13. Other duties as assigned.
Specific Knowledge / Skills / Abilities:
1. Proficient in all clinical software systems used to gather, report, and analyze data, as well as
all other software applications necessary to carry out job functions.
2. Excellent assessment, cognitive, and critical thinking skills a must.
3. Ability to make complex decisions, with decisive judgment, and act in situations that are
moderately to extremely difficult.
4. Familiarity with hospital billing and reimbursement, including but not limited to Claim Adjustment
Reason Codes, Remittance Advice Remark Codes, Revenue Codes, Medicare Code 44-
inpatient to outpatient, billable outpatient in a bed services; Medicare traditional IPPS 2 Midnight
Rule as it relates to case review requirements and hospital reimbursement for services
5. Excellent verbal and written communication skills, strong listening skills, problem- solving skills,
organizational skills, effective time management, ability to set priorities, and the willingness to
adapt quickly to changing priorities, if necessary.
6. Ability to read, understand and abstract information from handwritten patient medical records.
7. Ability to maintain confidentiality according to HIPAA regulations is required.
Specific Education / Certification:
1. BS in Nursing and licensed as Registered Nurse in the State of Texas required
2. Certification as an Accredited Case Manager (ACM) or Certified Case Manager (CCM) or
willingness to obtain within two years
3. Significant experience in the healthcare field, including a minimum of three to five years of
Utilization Review/Case Management experience in an acute care or managed care setting
4. Two to three years of experience in the denial management process preferred
5. Experience in the application of medical necessity screening criteria tools (MCG and/or
Minimum Position Qualifications:
Education: RN, Bachelors degree in Nursing/healthcare related field preferred
Experience: RN, three years of direct patient care experience in an acute care hospital in a leadership role preferred
Previous case management or utilization management experience preferred
License/ Certification: Current licensure in Texas or an approved compact state as a Registered Nurse or proof of application for licensure.
Covenant Health is celebrating nearly 100 years of serving Lubbock and our South Plains region. As the oldest and largest health system in Lubbock and the region, we currently employ over 5,200 people with a medical staff of over 600 physicians.
For nearly 100 years, Covenant has been driven by a mission of providing a Christian ministry of healing and caring for the whole person - mind, body and spirit. Our vision and differentiator is we are the only faith-based, integrated health network in the West Texas/eastern New Mexico region dedicated to a Christian ministry of healing.
As an expression of our mission, we believe we hold an important Covenant with our patients and try and treat every interaction as Sacred Encounters.
Our ministry includes six hospitals with over 1,100 licensed beds:
Covenant Medical Center - CMC
Covenant Plainview - PLV
Covenant Levelland - LVL
Trustpoint (joint venture: Rehab Hospital of Lubbock)
Covenant Medical Group (CMG)
Covenant Health Partners
Hospice of Lubbock
Covenant Health's total service area includes 25 counties that covers most of West Texas and eastern New Mexico. The service area covers approximately 750,000 people and approximately 35,000 square miles.
Covenant / St. Joseph Health (SJH) provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Covenant / St. Joseph Health (SJH) complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Positions specified as “on call, per diem” refers to employment consisting of shifts scheduled on as “as needed basis” to fill in for staff vacancies.