Case Manager-RN

The Christ College; Cincinnati (OH); On-site; USD 70,000 - 100,000; Full time

Job summary

The Christ Hospital is seeking a skilled Case Manager to oversee clinical reviews and discharge planning, ensuring patients receive appropriate care across the continuum.

Responsibilities include coordinating with payers, conducting utilization review, and guiding patients from admission through discharge with emphasis on quality, safety, and regulatory compliance.

Qualifications

• Experience with case management, utilization review, and discharge planning related to clinical or operational areas.
• Knowledge of advanced case management tools and methods.
• Understanding of regulatory and accreditation requirements.
• Proficient with PC-based software and database systems.

Responsibilities

• Clinical review of acute bedded patients and inpatients for medical necessity against InterQual and Milliman criteria.
• Monitor continued stay and level of care, communicating with physicians as needed.
• Coordinate with external payers to obtain or secure authorization for services.
• Develop discharge plans and educate patients and families on healthcare recommendations.
• Identify barriers to discharge and collaborate with multidisciplinary teams to resolve delays.

Skills

Case management

Utilization review

Discharge planning

Regulatory knowledge

Analytical skills

Time management

Cross-department collaboration

Education

Bachelor's Degree in Nursing

Job description

Job Description

To maintain high-quality, medically necessary, evidence-based care, and efficient treatment of all patients, regardless of payment source, by ensuring the patients receive the right care, at the right time, in the right place.

Case Management Model:

utilize an Integrated Case Management Model. Under this model the Case Managers will follow patients through the continuum while facilitating the functions of utilization review, care coordination, advocacy and discharge planning.

Responsibilities

• Clinical review of 100% acute bedded patients and potential inpatients at The Christ Hospital against medical necessity criteria (Interqual and Milliman) for appropriateness of admission and status. Communicate with physicians when alternatives to inpatient care are indicated by clinical review.
• Monitors cases for appropriateness of continued stay, level of care and services, and quality of care using approved screening criteria. Communicate with physicians when alternatives to inpatient care are indicated by clinical review. Refers cases as needed for second level of review.
• Work with external payers completing/securing authorization for all services provided.
• Identify/facilitate patient status from observation to discharge or inpatient as patient clinical condition warrants.
• Document all reviews and responses of third party payers in Midas/EPIC per UR proce
• Identifies potential delays in service or treatment and refers to the appropriate individuals within the multidisciplinary patient care teams for action/resolution. Track and trends avoidable day information in Midas per process.
• Interfaces with patient registration, financial councilors, Social Work, and patient financial services etc. to collaborate on financial issues.
• Assist in denial and appeal proce
• Develop a discharge plan based on screening and assessment tools utilized by the Case Manager. Education of the discharge plan including health care recommendations to the patient, family, caregiver, and other hospital personnel
• Work with external agencies and ancillary providers by completing discharge plans for services provided at an alternate level of care.
• Proactively identify potential barriers to discharge, for example: alternative levels of care, financial coverage issues, psycho/social behaviors, and self care challenges.
• Identifies potential delays in service or treatment and refers to the appropriate individuals within the multidisciplinary patient care teams for action/resolution.
• Determine outcomes of the discharge plan when follow-up care required by utilizing a discharge phone call process in congruence with the staff of the unit assigned.
• Facilitates daily huddles and multidisciplinary team rounds to include IS/SI, discharge plan, length of stay, barriers to discharge, and delays.
• Participate in hospital based committees as requested by management.
• Collect, analyze, and communicate data that includes but not limited to quality of care, patient safety, patient/staff/physician satisfaction operational efficiency and financial performance.
• Collects Core Measure data concurrently.
• Track and trends avoidable day information in Midas per process.
• Performs other duties as assigned, including for example participation in planning sessions for departmental activities.

Qualifications

KNOWLEDGE AND SKILLS:

Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.

EDUCATION:

Bachelor's Degree. Graduate of an accredited school of nursing with current licensure OR actively enrolled in a BSN program with completion within 3 years of hire date and graduate of an accredited school of nursing with current licensure.

YEARS OF EXPERIENCE:

3-5 years of medical/surgical nursing necessary, case management experience preferred

REQUIRED SKILLS AND KNOWLEDGE:

• Experience with case management, utilization review, and discharge planning that is related to the clinical or operational functional areas.
• Knowledge and application of a wide variety of advanced case management tools and methods.
• Knowledge of clinical and operations research methodology and design. Proficient in state of the art business trends, benchmarking, and case management tools and techniques.
• Ability to operate PC based software programs or automated database management systems.
• Expertise in meeting regulatory and accreditation requirements.
• Strong presentation, written and oral communication skills, with strong analytical and problem-solving skills as well as time/project management skills.
• Ability to work with a variety of disciplines and levels of staff across departments and the organization is required.

LICENSES & CERTIFICATIONS:

Licensed to practice in the State of Ohio

• Certified Case Management (CCM) or Accredited Case Management (ACM) desired.