Full Job Description
Coordinate care and service for a caseload of patients with complex needs throughout the continuum of care. Promote quality of care and timely, cost effective patient outcomes through regular communication with physicians, other caregivers and patient/family. Conduct admission and continued stay reviews for medical necessity, severity of illness and intensity of service. Coordinates proper admission status with the physician and obtains authorization for reimbursement. Conduct a comprehensive evaluation of the patient’s physical health status, functional capability, mental status, psychosocial needs, personal and community support systems, financial resources and environmental conditions by using all sources of data including interview with patient/family as necessary. Evaluate the patient’s medical and functional status, treatment plan and expected length of stay. Perform individual or family therapy, as appropriate. Collaborate with the patient/family, health care team and community agencies as indicated to develop and coordinate interventions and discharge plans. Assist in issuing letters of denial and/or hospital issued notices of non-coverage (HINN) within regulatory timeframe. Seek to improve quality of service by continuously developing and maintaining a knowledge base of community resources, insurance benefits, regulatory changes, standards and organizational competencies. Identify care or system variances, which impact negatively on quality and/or cost, and facilitate resolution through performance improvement initiatives. Serve as initial contact for swing bed referrals and oversight of patients while in swing bed program. Perform other related responsibilities as necessary.
Coordinates care and services for particular population of patients including conducting utilization review, establishing proper admission status in conjunction with the physician, facilitating patient and/or family participation in decision making regarding treatment and overseeing discharge plans.
Works collaboratively with providers to arrange post-discharge care and services in a timely manner, involving the patient and/or family in developing discharge plans.
Conducts admission and continued stay reviews for medical necessity, severity of illness and intensity of service. Coordinates proper admission status with the physician and obtains authorization for reimbursement in a timely manner.
Develop and maintain a collaborative team to evaluate and create process for denied authorizations in an effort to improve process and eliminate loss of revenue.
Provide quality psychosocial needs to patients and their family by formulating a diagnostic impression.
Provides efficient methods of work processing and workflow for the utilization function required with patient management.
Oversight and coordination of all patients admitted to swing bed program.
Complete initial review of potential swing bed patients, including appropriateness, review with accepting provider on call.
Update polices on case management, utilization review and swing bed.
Function effectively in an independent manner.
Master's degree in Social work or a graduate of an accredited school of nursing and currently licensed to practice in the State of Michigan. BCLS required upon hire and maintained throughout employment. 2-3 years of case management and/or utilization review experience preferred.