Full-Time RN Case Manager (UR Focused) | Texas

Schedule of Tele-Coverage Service

• Monday through Friday, 8:30am - 4:00pm cst

Daily Job Responsibilities:

• Actively work with ER/Hospitalist for any new obs/admission request to ensure proper status from admission.
• Ensures compliance with Condition of Participation (CoP) discharge planning.
• Identifies and escalates gaps/barriers related to inpatient and observation length of stay.
• Attend Patient/Family meetings as needed.
• Assesses patients at high risk for readmission. Identifies root cause for readmission. Develops plan and collaborates with multidisciplinary team regarding discharge planning to next level of care.
• Provides discharge care coordination for HHS, Hospice, ALF, and SNF. Communicates with health unit coordinator for appointments/follow ups and therapy re: DME needs prior to and upon discharge.
• Participates with other members of team regarding opportunities for improvement in standard work.
• Actively participates in utilization management process, admission process, and act as a case manager liaison with post acute providers (skilled nursing facilities, rehab, home health, etc.).
• Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's Scope of Service.
• Performs other duties as assigned.

Administrative Responsibilities:

• Utilization review on an ongoing basis.
• Lead monthly UR meeting includes monthly reports with trends and input. This will also be sent to CEO, CFO, CNO, and Hospitalist director + Med Surg manager.
• Aid in Insurance authorization coordination.
• Weekly meeting prn with PFS regarding authorizations and denied claims.
• Denial coordination with the business office on hospitalized patient denials. 
• Coordinate peer to peer requested by the business office and provide the business office supportive clinical information. 
• Prepare for Monthly UR meetings including monthly reports with trends and input.

Required Skills:

• 3+ years experience in prior case manager experience in the inpatient setting.
• Graduate of accredited school of nursing or education equivalency for licensing
• Proficiency with case management software platforms - InterQual and Milliman 
• Excellent written and verbal communication skills.

Highlights:

• Work from Home, get the time back spent traveling to and from work.
• Join a group of passionate individuals with a vision of Healthcare Equality.