RN Case Manager (Part Time) - West Penn Hospital

Highmark Health; Pittsburgh (Allegheny County); On-site; USD 90,000 - 120,000; Full time

Job summary

Allegheny Health Network is seeking a registered nurse skilled in care management to lead coordination of care across settings, promote efficient transitions, and support optimal resource use for diverse patient populations.

The role emphasizes collaboration with care teams, securing approvals with payers, documenting outcomes, and educating staff while abiding by regulatory standards and HIPAA requirements. Strong critical thinking and communication are essential for success.

Qualifications

• Bachelor’s degree in nursing or equivalent, or 6 years relevant experience.
• At least 3 years in a clinical nursing role.
• Current PA RN licensure or multi-state licensure via eNLC.
• Professional certification within 5 years of start date.
• Strong critical thinking, communication, and collaboration skills.
• CPR certification and background clearances as required.

Responsibilities

• Assumes role in assessment of patient physical, psychosocial, and economic needs for effective transition of care planning to a variety of levels of care.
• Facilitates development and communication of the continuum of care transition plan to appropriate health service providers.
• Documents, verifies, and validates data to monitor and evaluate interventions and outcomes.
• Obtains pre-certifications from third party payers and placement to appropriate level of care prior to hospitalization.
• Documents, monitors, and reports clinical denials/appeals and retrospective payer audit denials.
• Maintains knowledge of care management regulations and adheres to policies and HIPAA requirements.
• Serves as an educational resource to AHN staff regarding utilization review practice and guidelines.
• Performs continued education and professional growth.

Skills

Care coordination

Assessment

Communication

Regulatory compliance

Denials/Appeals

Education

Bachelor’s Degree in Nursing

Nursing Diploma

6 years relevant experience

Job description

Company :

Allegheny Health Network

Job Description :

GENERAL OVERVIEW:

Registered nurse who is proficient in the coordination of care and manages coordination of care in accordance with recognized standards of practice for Care Management. Professional role model utilizing expertise in care management to promote a collaborative professional environment that supports excellence of care and achievement of optimal resource utilization. Also facilitates appropriate LOS, patient satisfaction and reimbursement for all patients.

ESSENTIAL RESPONSIBILITIES:

• Assumes role in assessment of patient physical, psychosocial, and economic needs for effective transition of care planning to a variety of levels of care.
• In collaboration with the care team, facilitates the development and communication of the continuum of care transition plan to appropriate health service providers.
• Documents, verifies, and validates specific data required to monitor and evaluate interventions and outcomes. Interviews and collects patient specified data and chart review related to readmission.
• Knowledgeable of and complies with accreditation and regulatory requirements. Integrates performance improvement principles and customer service principles into all aspects of job responsibilities.
• Obtains or ensures acquisition of appropriate pre-certification authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party guidelines. Obtains or facilitates acquisitions of urgent / emergent authorizations, continued stay authorizations and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements.
• Documents, monitors, intervenes/resolves and reports clinical denials/appeals and retrospective payer audit denials. Collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor and third party payers.
• Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental commercial payer guidelines. Adheres to the policies, procedures, rules, regulations and laws of the hospital and all federal and state regulatory bodies. Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
• Assumes responsibility for AHN required continued education and own professional growth.
• Performs other duties as assigned or required.

QUALIFICATIONS:

** Minimum**

• Bachelor’s Degree in Nursing -OR- Bachelor’s Degree and Nursing Diploma -OR- 6 years of relevant experience in lieu of a degree
• 3 years in a clinical nursing role
• Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
• Professional Certification within 5 years of start date. Incumbents in role as of 12/1/2022 have until 12/31/2025 to obtain
• Critical thinking and problem solving
• Flexibility and adaptability to change
• Strong communication and collaboration skills with ability to tailor style according to target audience (providers, peers, clinical team members, patients, families)
• CPR – American Heart Association
• Act 34 Criminal Background Clearance Certificate
• Act 33 Child Abuse Clearance Certificate
• Act 73 FBI Fingerprinting Criminal Background Clearance Certificate

Preferred

• Nationally recognized Case Management Certification
• Transition planning and understanding of community and facility resources
• Knowledge of motivational interviewing techniques
• BSN

LICENSES or CERTIFICATIONS

Required

• None

_ Preferred

• ACM Certification (Accredited Case Manager) - American Case Management Association - American Case Management Association
• Case Management - American Board of Occupational Health Nurses (ABOHN) and
  Certified Case Manager (CCM)
• Commission for Case Manager Certification (CCMC)

_ Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

_ Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

_As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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