RN Care Manager - Casual

Socket.dev; Indiana (PA); On-site; USD 75,000 - 95,000; Full time

Job summary

Socket.dev is seeking a skilled nurse case manager in Pennsylvania to support patient care goals by assessing eligibility, medical necessity, and coverage for each encounter. You will coordinate care across transitions, leveraging collaboration with nursing and leadership to optimize outcomes.

The role emphasizes clear communication with physicians, payers, and hospital staff, plus ongoing patient and family education and strict adherence to discharge planning processes in a changing healthcare

Qualifications

• Diploma/associates/bachelor in nursing or health-related field
• 3-5 years medical/surgical nursing, ED experience preferred
• Case management experience in Acute, Psychiatric, or ED
• Medicare/MA/MCO and third party reimbursement
• Licensure as RN in Pennsylvania

Responsibilities

• Collaborate with nursing and case management leadership to meet organizational goals and patient care initiatives.
• Determine patient insurance eligibility, status, and benefit coverage with each patient encounter.
• Utilize medical necessity criteria to determine admission and continued stay.
• Ensure patient moves efficiently through care and resources with cost efficiency.
• Communicate with medical staff, offices, and ancillary departments regarding referrals and authorization.
• Identify issues during concurrent cases for focus and cost impact analysis.
• Analyze outcomes using data from Case Manager daily work.
• Act as liaison to pre-post hospital care providers and community health resources.

Skills

Nursing leadership

Case management

Medicare/MA/MCO reimbursement

InterQual

Milliman

Communication skills

Office suite

Education

Nursing diploma/degree

Tools

InterQual

Milliman

Job description

Essential Duties and Responsibilities

In this role you will be:

• Working with nursing leadership and case management leadership to fulfill organizational goals and patient care initiatives.
• Determining patient insurance eligibility, status, and benefit coverage with each patient encounter.
• Utilizing medical necessity criteria specific to the managed care/insurance plan to determine appropriateness of admission and continued stay.
• Assuring that the patient moves efficiently through all aspects of care and treatment with optimal utilization of resources and cost through ongoing case management and communication with all members of the healthcare team.
• Effectively communicating in a timely, interactive, and appropriate manner with medical staff, offices, and required ancillary departments regarding patient referral, authorization, and medical necessity and criteria.
• Identifying issues during concurrent cases to be targeted for focus study to determine impact on cost and reimbursement.
• Analyzing and evaluating pre-established outcomes with report-specific data extracted from the Case Manager daily work.
• Acting as a liaison to pre-post hospital care providers along with community health resources to ensure continuation of patient care.
• Providing education to patients, families, and hospital staff related to provider guidelines, discharge planning, and resource information as appropriate.
• Participating in multi-disciplinary discharge planning meetings along with attending committee and task-oriented meetings as assigned.
• Documenting and maintaining accurate and pertinent information related to each concurrent patients through the utilization of a software system via laptop computer.
• Playing an integral role in the identification of risk, quality, and infection control issues through ongoing, concurrent chart review and reporting.
• Complying with hospital policies and procedures on safety, infection control, and performance improvement.
• Utilizing thorough understanding of third party payer systems as they relate to utilization management and discharge planning.
• Adaptable to continuous change.
• Utilizing practical knowledge of the nursing process and continuity of care.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Qualifications

Required:

• EDUCATION: Diploma Program, Associate's, or Bachelor's Degree in Nursing or other health-related field
• EXPERIENCE:
  • 3-5 years medical/surgical nursing, ED experience preferred
  • Case Management experience in Acute, Psychiatric, or ED
  • Medicare/MA/MCO and third party reimbursement
  • Interqual or Milliman experience
  • Office Suite experience
• LICENSURE/CERTIFICATION:
  • Case Manager Certification preferred
  • Licensure as Registered Nurse in Pennsylvania by State Board of Nursing Examiners

Shifts: Varied/Days