Case Manager - RN

Universal Health Services; Aiken (SC); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Sign On Bonus

Referral Program

PTO and Benefits

Medical/Dental/Vision

Job summary

Universal Health Services is seeking a Case Manager (RN) at Aiken Regional Medical Centers in Aiken, SC to oversee admission reviews, continuity of care, and discharge planning. The role emphasizes collaboration with surgeons, nurses, social work, and payers to optimize patient flow and minimize denials.

Responsibilities include chart reviews for admission and stay, coordinating with the SW/DCP team, and helping prevent delays by proactive care management while ensuring safe transitions on the

Qualifications

• Diploma or associate degree from an accredited Registered Nursing program; BSN preferred.
• Minimum of 3 years experience in acute-care hospital or related setting; utilization review or case management experience.
• SC RN license or compact state license.

Responsibilities

• Performs admission, concurrent and retrospective chart reviews to certify appropriateness of admission, accurate status, continued stay and reduce denial risks.
• Follows department processes for management of denied cases and referrals for review or appeal.
• Monitors patients for progression of care and readiness for discharge; collaborates with SW/DCP for timely transitions.
• Performs discharge planning to ensure timely transition of care on the assigned unit.
• Collaborates with nursing and interdisciplinary team to anticipate discharges and communicates with clinical staff.
• Maintains relationships with insurance companies to obtain payment authorization and manage denials while patients are in-house.
• Documents and justifies admissions/continued stay to support medical necessity.
• Identifies avoidable hospital days and initiates interventions to minimize delays.
• Educates medical staff on utilization of hospital days and resources; makes referrals to Infection Control, Wound Care, Nutrition, and Peer Review as needed.
• Contributes to development of clinical practice guidelines for designated patient groups.

Skills

Private insurance knowledge

Medicare criteria knowledge

Healthcare financial systems

Benchmarking practices

Interdisciplinary collaboration

Computer skills

Education

RN Diploma or Associate degree

BSN preferred

Job description

Responsibilities

Case Manager (RN) – Fulltime at Aiken Regional Medical Centers, located in Aiken, South Carolina.

The Case Manager is responsible for admission, concurrent and retrospective medical review of all patient populations for documentation of appropriateness of admission and continued stay. This position requires close collaboration and communication with payers to reduce risk of denials by continued management of all assigned cases from admission to discharge. Responsible for managing assigned patient population for progression of medical management and readiness for discharge. Includes initiation of interventions to reduce avoidable days, opportunity days and delays in care; works in collaboration with interdisciplinary team members internal and external to the organization; participates in process improvement and evaluation process related to the management of patient care and resource utilization. Responsible for working in close collaboration with the assigned SW/DCP on the floor to ensure a safe and timely transition of care, with the goal of management of LOS and utilization of resources on their assigned units. Performs discharge planning as needed to ensure timely transition of care of all patients on the assigned unit.

Duties:

• Performs chart reviews (admission, concurrent and retrospective, as necessary) for all payor sources in order to certify appropriateness of admission, accurate status, continued stay and reduce denial risks.
• Follows department processes for management of denied cases, refers these cases for Peer to Peer or for VH appeal. Sends updated clinical to request reconsideration when appropriate.
• Follows department process for referrals to VERSALUS HEALTH for all OBS cases and follows up after review to facilitate order status changes as appropriate.
• Monitors all patients on their assigned floor for progression of care and clinical readiness for discharge and works with their SW/DCP partner to limit delays in transition of care by performing discharge planning as needed in the assigned unit.
• Works in collaboration with partner, nursing, and other members of the Interdisciplinary team to anticipate discharges for the next day and provides this information to clinical staff at the end of each day.
• Maintain strong relationship with insurance companies to share clinical information for payment authorization and limit risk of denials. Follows and continues to work denied cases in an effort to overturn denials while patients are still in house.
• Collaborates with members of the healthcare team to ensure documentation supports admission or continued stay when documentation is not clear to ensure appropriateness of acute hospital stay.
• Identifies and documents, and manages avoidable hospital days according to defined criteria and initiates appropriate intervention as necessary to minimize discharge delays.
• Educates medical staff, nursing and other members of the healthcare team regarding utilization of hospital days and resources.
• Identifies and makes referrals to other departments such as Infection Control, Wound Care, Nutrition/Dietary, and Peer Review as appropriate.
• Collaborates with Medical staff and other departments as appropriate to facilitate development of clinical practice guidelines for designated patient groups.

Benefits

• Sign On Bonuses for select positions
• Unlimited Employee Referral Bonus Program
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• Tuition/Certification Reimbursement after 6 months
• Culture of Excellence - Employee Recognition program
• Challenging and rewarding work environment
• Clinical Nursing Ladder opportunities
• SoFi Student Loan Refinancing program
• 401(K) with company match and discounted stock plan
• Career development opportunities within UHS and its 300+ Subsidiaries!
• More information is available on our Benefits Guest Website: uhsguest.com

Qualifications

Education requirements: Diploma or associates degree from an accredited Registered Nursing program. BSN preferred.

Work experience requirements: Minimum of 3 years experience in acute-care hospital or related setting; previous utilization review or case management experience.

Required licenses/certifications/courses: SC RN license or compact state license.

Required skills, knowledge and abilities: Knowledge of private insurance, Medicare criteria for hospitalization, understanding of healthcare financial systems, benchmarking practices; Experience in facilitating change through interdisciplinary collaboration; computer skills.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.