RN Care Manager - Casual

IRMC; Indiana (PA); On-site; USD 70,000 - 100,000; Full time

Job summary

IRMC in Pennsylvania seeks an experienced RN Case Manager to collaborate with nursing and case management leadership. You will determine insurance eligibility, assess medical necessity, and coordinate discharge planning with patients, families, and the health care team.

Responsibilities include communicating with staff on referrals, authorizations, and coverage criteria, ensuring efficient patient movement, and supporting ongoing cost-effective care across the continuum.

Qualifications

• 3–5 years medical/surgical nursing experience.
• Case management experience in Acute, Psychiatric, or ED.
• Licensure as RN in Pennsylvania.
• Case Manager Certification preferred.

Responsibilities

• Collaborate with nursing and case management leadership to meet patient care goals.
• Determine patient insurance eligibility, status, and benefit coverage.
• Assess medical necessity and appropriateness of admission and continued stay.
• Coordinate discharge planning and resource continuation with care teams.
• Communicate with staff regarding referrals, authorizations, and criteria.
• Document and maintain patient information in the software system.

Skills

Case management

Medicare/MA/MCO knowledge

Interqual or Milliman experience

Discharge planning

Communication with medical staff

Education

Nursing or health-related degree

Tools

Microsoft Office

Job description

• 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

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.