RN Care Manager - Union Clinical Care Management FT Days

Atrium Health; Monroe (NC); On-site; USD 70,000 - 100,000; Full time

Job summary

Advocate Health Care is seeking an experienced Registered Nurse in Utilization Management to drive care coordination and discharge planning across hospital stays. You will partner with physicians, social workers, and care teams to ensure timely, appropriate transitions and compliant utilization reviews.

The role requires strong clinical judgment, 3+ years of nursing experience, and proficient use of electronic health records.

Qualifications

• Typically requires 3 years of related nursing experience.
• RN licensure or registration required.
• BSN preferred for advanced practice and leadership opportunities.

Responsibilities

• Conducts comprehensive nursing assessments and develops care plans.
• Coordinates discharge planning and continuity of care.
• Initiates internal and external referrals and conducts utilization reviews.
• Collaborates with healthcare team to optimize patient flow and prevent unnecessary delays.
• Maintains knowledge of healthcare regulations and payer requirements.
• Educates staff on admission status, utilization management, and care coordination.

Skills

Case management

Care coordination

Discharge planning

CMS/UM knowledge

Communication skills

Education

RN licensure

BSN preferred

Job description

• Conducts complete assessments, establishes appropriate plans, and initiates interventions within desired timeframes. Collaborates and negotiates effectively with patient, family, and team while striving to achieve patient and organizational goals with regard to patient’s care needs, choice and satisfaction when discharge planning/transitioning care. Utilizes patient/family strengths in the problem-solving process, involving the patient/family and team in the decision-making process beginning on admission and continuing throughout patient’s hospital stay.
• Provides continuity of care and discharge planning services compliant with regulatory standards by providing coordinated relevant options and services based on assessed needs to ensure patient/family and healthcare team is informed and able to proceed with accountabilities in a timely manner. This includes participating in the communication process to facilitate a smooth transition for patient, family, and staff when patients are transferred.
• Provides case management services related to various levels of health care, finances, housing, family discord, or illness adjustment, based department scope. This may include managing family dynamics and crisis situations in a timely and professional manner, using community resources effectively, and educating patient/family regarding access to and use of services.
• Initiates internal and external referrals to assure timely progression of care and transitions. Documents discharge planning interventions and utilization review activity per department and medical center standards in a timely manner. Performs and documents accurate and timely concurrent and retrospective reviews based on approved established criteria as required by department standards.
• Communicates effectively with the healthcare team. Works in partnership with Social Work and unlicensed support personnel to effectively establish and implement a safe plan of care. Serves as an active member of the MDR and works closely with medical staff, hospital departments and ancillary services in identification and resolution of barriers to discharge, expediting care delivery to avoid delays in timely service provision, and implementing and reporting care coordination, discharge planning and utilization management (UM) activities.
• Collaborates with managers, physicians, medical directors, advisory groups, and treatment teams for issues related to physician practices and best practices for the patient’s plan of care. Refers cases to physician advisor as needed to ensure efficient progression of care, accurate status, and compliance with regulatory guidelines.
• Remains knowledgeable in issues of healthcare regulations, reimbursement issues, impact on length of stay and community resources. Completes UM activities as required based on local structure to include providing clinical updates to payers and/or external review organizations, collecting data, coordinating denial activity, supporting UM activity, and managing avoidable delays. Delivers CMS regulatory notices within CMS established timeframes, as appropriate based on-site guidelines.
• Develops and maintains productive relationships with community-based agencies and networks by representing Advocate Health Care in a positive manner working collaboratively, internally, and externally, to meet patient/family needs. Works in collaboration with Advocate Ambulatory Care Management and Continuing Health to meet common goals and outcomes.
• Serves as an educator and expert resource to medical and hospital staff regarding admission status and acute care criteria, utilization management issues, care coordination and discharge planning needs, and relevant regulatory requirements.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Major Responsibilities

• Conducts complete assessments, establishes appropriate plans, and initiates interventions within desired timeframes. Collaborates and negotiates effectively with patient, family, and team while striving to achieve patient and organizational goals with regard to patient’s care needs, choice and satisfaction when discharge planning/transitioning care. Utilizes patient/family strengths in the problem-solving process, involving the patient/family and team in the decision-making process beginning on admission and continuing throughout patient’s hospital stay.
• Provides continuity of care and discharge planning services compliant with regulatory standards by providing coordinated relevant options and services based on assessed needs to ensure patient/family and healthcare team is informed and able to proceed with accountabilities in a timely manner. This includes participating in the communication process to facilitate a smooth transition for patient, family, and staff when patients are transferred.
• Provides case management services related to various levels of health care, finances, housing, family discord, or illness adjustment, based department scope. This may include managing family dynamics and crisis situations in a timely and professional manner, using community resources effectively, and educating patient/family regarding access to and use of services.
• Initiates internal and external referrals to assure timely progression of care and transitions. Documents discharge planning interventions and utilization review activity per department and medical center standards in a timely manner. Performs and documents accurate and timely concurrent and retrospective reviews based on approved established criteria as required by department standards.
• Communicates effectively with the healthcare team. Works in partnership with Social Work and unlicensed support personnel to effectively establish and implement a safe plan of care. Serves as an active member of the MDR and works closely with medical staff, hospital departments and ancillary services in identification and resolution of barriers to discharge, expediting care delivery to avoid delays in timely service provision, and implementing and reporting care coordination, discharge planning and utilization management (UM) activities.
• Collaborates with managers, physicians, medical directors, advisory groups, and treatment teams for issues related to physician practices and best practices for the patient’s plan of care. Refers cases to physician advisor as needed to ensure efficient progression of care, accurate status, and compliance with regulatory guidelines.
• Remains knowledgeable in issues of healthcare regulations, reimbursement issues, impact on length of stay and community resources. Completes UM activities as required based on local structure to include providing clinical updates to payers and/or external review organizations, collecting data, coordinating denial activity, supporting UM activity, and managing avoidable delays. Delivers CMS regulatory notices within CMS established timeframes, as appropriate based on-site guidelines.
• Develops and maintains productive relationships with community-based agencies and networks by representing Advocate Health Care in a positive manner working collaboratively, internally, and externally, to meet patient/family needs. Works in collaboration with Advocate Ambulatory Care Management and Continuing Health to meet common goals and outcomes.
• Serves as an educator and expert resource to medical and hospital staff regarding admission status and acute care criteria, utilization management issues, care coordination and discharge planning needs, and relevant regulatory requirements.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.

Education

Graduate of a Board of Nursing approved nursing education program (RN)

License/Registration/Certification

• Preferred Bachelor of Science degree in Nursing (BSN).
• Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, (where applicable) current RN license or temporary license as a Registered Nurse

Years Of Experience

• Typically requires 3 years of related nursing experience.
• Clinical experience within the assigned population.
• Extensive knowledge of disease processes and clinical outcomes.
• Case Management experience or background preferred.
• Strong critical thinking and analytical skills preferred.
• Appropriate Professional certification preferred within 3 years of hire

Knowledge Skills And Abilities

• Ability to prioritize and organize work.
• Effective communication skills.
• Utilization of critical thinking and timely decision making.
• Ability to navigate the Electronic Health Record.
• Basic utilization of MS Office products.
• Knowledge of Medicare A and B guidelines.
• Knowledge of Managed Care program requirements/implications.
• Ability to apply elements of Utilization Management programs.

Physical REQUIREMENTS

• Must be able to sit up to approximately 50 percent of the workday; stand and walk for the equivalent of several blocks at a time.
• Must lift up to 10 lbs. continuously, up to 20 lbs. frequently, and up to 50 lbs. occasionally.
• Manual dexterity required for operation computer and calculator.
• Visual acuity required for facilitating review of written documents/computer screens, medical records, and to record information accurately.
• Clear verbal communications and hearing acuity required for receiving instructions and converse on standard telephone.
• Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.
• Exposed to normal office environment; including usual hazards related to operating electrical equipment.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.