Case Manager (Per-Diem)

Larkin Community Hospital, Inc.; Town of Florida (NY); On-site; USD 85,000 - 110,000; Full time

Job summary

Larkin Community Hospital, Inc. in Hialeah, FL, is seeking an experienced Case Manager to coordinate patient care from admission to discharge.

The role requires reviewing medical necessity, securing insurance approvals, and collaborating with physicians and care teams. You will assess patients within 24 hours of admission, manage concurrent reviews, and guide discharge planning while ensuring cost-effective and quality care.

Qualifications

• Bachelor's degree required; master's preferred.
• Substantial clinical experience; C.M. experience preferred.
• Licensing: CCM/ACM preferred; foreign medical graduate or RN preferred.
• Experience with payer portals and prior authorizations.

Responsibilities

• Performs and documents patient assessment within 24 hours of admission.
• Checks prior authorizations and initiates insurance authorization.
• Navigates payer portals to obtain approvals for admission and stay.
• Performs concurrent reviews and communicates with HMOs daily.
• Determines level of care and plans medically necessary services.
• Develops discharge planning and coordinates transfer procedures.
• Engages in PI programs to identify improvement opportunities.
• Educates patients and families about discharge resources.

Skills

Medical knowledge

Communication skills

Self-driven

Regulatory knowledge

MS Office

Education

Bachelor's degree

Master's degree

Tools

Medhost EMR

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Hialeah, FL, US

Qualifications:

• Experience
  • Previous C.M. Experience
  • Substantial clinical experience
• Education
  • Bachelor's degree (required)
  • Masters (preferred)
• Licensing
  • Foreign Medical Graduate or Registered Nurse (preferred)
  • CCM (Certified Case Manager) (preferred)
  • ACM (Accredited Case Manager) (preferred)

Responsibilities:

• Performs and documents patient assessment within 24 hours of admission
• Checks prior authorizations initiative by admitting
• Knowledge navigating and using payer portals
• Performs concurrent reviews
  • Contacting all HMO’s on a daily basis and provides clinical information to obtain insurance authorization for the patient’s admission and continued stay
• Indicates the appropriate level of care and utilization of services needed
• Establishes criteria for medically necessary services
  • Knowledgeable of Milliman Care and Interqual Guidelines
• Develops a plan of care for patients from admission to discharge.
• Promotes the most efficient and cost-effective use of services
• Curtails the performance of inappropriate and/or duplicate services
• Encourages standardization of medical practice patterns
• Enhances the quality of healthcare
• Performs concurrent reviews for patients to ensure that extended stays are medically justified and are documented in patient's medical records.
• Calculates and manages the lengths of stay and continued-stay days for patients.
• Evaluating the patient’s condition and readiness for discharge planning
• Communicate and assist the physicians in the planning and coordination of patients discharge planning
• Management of transfer procedures
• Management of the guardianship process
• Able to discuss and educate patient/family regarding discharge planning and resources available after discharge. Clearly specifies all the information discussed with the patient and/or family regarding the patient’s discharge plan.
• Participates in PI programs through the identification of opportunities for improvement, data collection, evaluation of findings, improving the process, applying knowledge and incorporates into practice
• Scheduling Peer-to-Peer reviews with payors
• Proactively identifying and resolving issues that could lead to denials

Skills:

• Familiarity with Medhost electronic medical records
• Extensive medical knowledge
• Self-driven (work and education)
• Keeps knowledge up to date by reading literature and participating in outside continued education meetings, training, and conferences
• Working knowledge of regulatory agencies
• Excellent human relations and communication skills (verbal and written) to maintain good rapport and effective working relationships with medical staff, nursing staff, and other ancillary department staff throughout the hospital
• Excellent organizational skills and attention to detail
• Ability to convey care plan to physicians and the medical team
• Proficient with Microsoft Office Suite or related software.