Case Manager

Overall Job Summary

The Case Manager works closely with the Revenue Cycle, Insurance and Clinical teams to facilitate the coordination of care from admission through discharge with a focus on realistic treatment outcomes within the scope of available resources. Oversees the assessment, planning,facilitation, coordination, evaluation and advocacy for options and services to meet the patients comprehensive health needs and to promote quality cost effective outcomes. Ensures clinically required care is available under insurance policy, approved in a timely manner to prevent delays in clinical care, coordinated referral or transfer to an alternate provider where clinically required care is avialble and within patient network. Facilitates commitment to providing “patients first” solutions in support of the multidisciplinary healthcare team and the organizations fiscal stewardship. Actively promotes communication and coordination between members of the interdisciplinary teams and the payer to minimize fragmentation of services and to maximize outcomes.

  • Hours
    As per contract
  • Professionally Responsible To
    Head of Department
  • Reports To
    Head of Department

Main Responsibilities

  • The role includes advocacy & education, facilitation, transition & financial management, outcomes & psychosocial management in order to promote quality, safe and timely transition through the healthcare system. The Case Manager will coordinate all appropriate clinical providers and access appropriate services to progress the patient’s episode of care in a timely manner.
  • Assessment of the patient’s health and psychosocial needs is conducted per established guidelines.
  • Close collaboration with the Interdisciplinary team is essential to achieve expected outcomes in a timely manner. Case Management plan is developed collaboratively with the interdisciplinary team, patient and family to maximize health care responses, quality and cost effective outcomes, incorporating patient and family goals, expectations, and preferences into the development of the Interdisciplinary Plan of Care.
  • Care Facilitation along the Continuum of Care, monitoring against Clinical Pathway, and facilitation of transition plans
  • Patient education and support is provided to ensure a smooth transition along continuum of care paradigm.
  • Patient centered team meetings are planned and conducted to coordinate healthcare team members and Insurance payers to achieve treatment outcomes and discharge planning goals.
  • Education is provided to the interdisciplinary team, the patient and the family about treatment options, community resources, insurance benefits and psychosocial concerns to ensure timely and informed decisions.
  • Patient and family are empowered to problem solve to achieve desired outcomes and promote patient self-determination.
  • Appropriate resources are identified to provide discharge services and promote a safe transition to the next most appropriate level of care.
  • Proactive Discharge plan is developed in collaboration with healthcare team and family and meets patient needs and financial requirements.
  • Culturally competent care is displayed to identify the patient’s cultural needs and incorporate them in the development of the discharge plan.
  • Additional department, organization, or network activities are completed per established objectives.

Interdisciplinary Resource Utilization:

  • Facilitation of Resource Utilization- ensuring the available funding meets the clinical needs.
  • Links the physician staff with finance.
  • Possesses working knowledge of patient’s benefits under Insurance contract to ensure patient care is rendered to the maximum stipulation but does not exceed the providers’ provision for cost of care and collaborations with team to obtain documentation to support medical necessity.
  • Communication and coordination is actively promoted between members of the interdisciplinary team, the payer and the community to minimize fragmentation of services and to maximize outcomes.
  • Appropriate use of health care services and allocation of resources is encouraged to improve quality of care and maintain a balance with cost effective care on a case by case basis.

Medical and Insurance Documentation:-

  • Facilitation of accurate medical documentation and health insurance documentation. Work with Physicians to ensure medical documentation is a true and accurate reflection of patient condition, care needs supported by clinical justification of care prescribed and severity of illness and risk assessment.

  • Documentation is completed in adherence to department standards.

Qualifications:-

Essential:

  • Diploma or Bachelors in Nursing. 
  • Minimum 5 years in Healthcare enviroment in clinical role or with relevant revenue cycle management experience.
  • Minimum 3 years in managerial role.
  • Minimum 2 years in case management.
  • Current valid nursing license in home country.
  • Proficiency with Microsoft Office suit.
  • Fluent in written and spoken English.
  • Self-motivated.
  • Able to work independently.
  • Able to work with multidisciplinary teams.
  • Able to prioritize and work under pressure.
  • Uses own initiative and is able to make decisions.
  • Good knowledge of revenue cycle and insurance plans.

 

Preferred:

  • Certification in Healthcare management.
  • 5 years as registered Nurse.
  • DOH license.

Job Specific Skills and Abilities

  • Proficiency with Microsoft Office suite.
  • Fluency in written and spoken English.
  • Self-motivated.
  • Able to work independently.
  • Able to work with multidisciplinary teams.
  • Able to prioritize and work under pressure.
  • Uses own initiative and able to make decisions.
  • Good knowledge of revenue cycle and insurance plans.