Care Manager

Appalachian Regional Healthcare (ARH); Beckley (WV); On-site; USD 60,000 - 90,000; Full time

Job summary

Appalachian Regional Healthcare (ARH) is seeking a Care Manager to coordinate patient management across the continuum of care, ensuring appropriate utilization, discharge planning, and cost-effective outcomes. The role engages with physicians, nursing, payers, and the care team to optimize patient flow and resource use.

Responsibilities include managing a caseload from preadmission to discharge, monitoring medical necessity, and leading discharge planning meetings while advocating for patients

Qualifications

• Associate's Degree in Nursing with active state license.
• Bachelor's degree in Nursing preferred; must be obtained within 5 years.
• 4-6 years of nursing experience preferred.
• Advanced problem-solving and decision-making skills.
• Strong multi-tasking abilities and flexibility.

Responsibilities

• Manage an assigned caseload from preadmission to discharge.
• Oversee admission appropriateness and ongoing care plan.
• Coordinate communication with third-party payers and Utilization Committee.
• Identify issues and address denials promptly.
• Collaborate with physicians and multidisciplinary teams on goals and plan.
• Lead discharge planning meetings and document outcomes.
• Advocate for patient/family and respect directives.
• Stay current with case management developments and pursue certification if available.
• Monitor regulatory guidelines and ensure care continuity.
• Monitor length of stay and address barriers to discharge.
• Participate in denials management.
• Contribute to data collection for outcomes analysis.
• Assess level of care and documentation completeness.
• Perform other related duties.

Skills

Problem solving

Multi-tasking

Communication skills

Team leadership

Discretion with sensitive information

Education

Associate's Degree Registered Nurse (licensed in state of employment)

Bachelor's Degree Nursing

LPN Required

RN Preferred

Job description

Overview

The Care Manager is accountable for outcomes as related to providing coordination of patient management through the continuum of care. Responsible for financial, clinical, and discharge planning evaluation for each assigned patient. Assures payment for services rendered, coordinates care, manages resources, and facilitates each patient encounter for efficient and effective outcomes as related to quality, clinical and cost areas.

Special Instructions

Coordinates comprehensive patient care across the healthcare continuum by assessing clinical and psychosocial needs, facilitating appropriate levels of care and discharge planning, coordinating services and resources, and collaborating with physicians, nursing, and payers, and interdisciplinary teams. Monitors length of stay, medical necessity, utilization, barriers to discharge, discharge readiness, and readmission risk while advocating for safe, timely cost-effective patient outcomes.

Responsibilities

• Manages an assigned caseload of patients from preadmission to discharge.
• Assumes responsibility for admission appropriateness (medical necessity), (outpatient, observation, inpatient admission), continued stay, and medical record monitoring
• Coordinates communication with third party payers, external review agencies and the Utilization Committee.
• Identify managed care issues and address promptly as related to denials management
• Coordinates and collaborate with physicians, provider, multidisciplinary team and other health care professionals concerning patient’s goals, plan of care and progress.
• Revise and adjust on a daily basis the plan of care to accommodate the needs of the individual patient based on continuing assessment of patient condition.
• Leads discharge planning multidisciplinary team meetings, ensures documentation of meetings
• Advocate for the patient/family and is knowledgeable of and act in accordance with legal principles of consent, healthcare proxies (power of attorney for healthcare) and advance medical directives.
• Stays abreast of developments in the case management field and seeks ongoing education to enhance practice skills. Care Management is willing to seek certification in case management field if made available through ARH.
• Stays abreast of regulatory agency guidelines as pertains to area of practice
• Initiate and monitor clinical care guidelines and analyze positive and negative variances
• Ensure continuity of care through formulation of discharge plan on admission and follow through until patient is discharged.
• Ensure appropriate use of resources.
• Monitor patient care for appropriate use of resources.
• Monitors length of stay on a concurrent, weekly, and monthly basis. Ensures that length of stay is appropriate based on medical necessity. Works with medical staff, hospital staff, and others to overcome barriers to discharge.
• Monitors in-house denials for extended lengths of stay.
• Participates in the denials management process to help ensure establishment of and adherence to processes that will minimize denials by third-party payers.
• Participates as a member of the Utilization Committee
• Assists in the collection of data to trend and analyze outcomes for identification of improvement opportunities.
• Participates in data collection, specific to outcomes data.
• Assesses the appropriateness of the level of care; diagnostic testing and clinical procedures; quality and clinical risk issues; and documentation of medical record completeness.
• Performs other related duties as assigned.

Qualifications

• Associate's Degree Registered Nurse (licensed in state of employment) from an accredited school for nursing Preferred
• Bachelor's Degree Nurisng; Must be obtained within 5 years Preferred
• 4-6 years 5 Years of nursing experience may be considered with demonstration of skills required for the position. Preferred
• Advanced knowledge of problem solving and decision making skills.
• Strong multi-tasking abilities with the ability to handle competing deadlines; flexible and adaptable.
• Ability to deal tactfully with customers and community.
• Advanced communication skills used to lead a team.
• Advanced execution and delivery (planning, delivering, and supporting) skills.
• Ability to consider the relative costs and benefits of potential actions to choose the most appropriate one.
• Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients.
• Mastery knowledge of phases of care transitions and resources available for patients.
• Mastery of digital literacy skills.
• Ability to handle sensitive information ethically and responsibly.
• RN Preferred
• LPN Required