Job Summary:
The case manager will facilitate modifications to clinical documentation via physician clarity or addendum, through extensive concurrent interactions with physicians and other clinicians in order to reflect appropriate clinical severity, complications and co-morbidity.
The specialist shall concurrently review and evaluate selected patient's medical records for overall quality and completeness. The case managers role is to ensure that health care services are administered with quality, cost efficiency, and within compliance.
Job Duties:
Consistently complies with the guidelines set forth by accrediting bodies. Reviews medical records of hospitalized patients to identify the most appropriate principle diagnosis and assign a working DRG. Performs review to ensure medical necessity of hospitalization and ensure DRG accurately reflects the principal diagnosis and all comorbid conditions, after study. Educates IDT on clinical documentation and coding guidelines. Develops and conducts ongoing CDI education for members of the healthcare team. Utilizes a compliant query process per guidelines and policy when conducting all queries. UR/CDI will support and implement quality measures as identified by department manager. UR/CDI will help identify opportunities for performance improvement. Identifies actual and potential delays in service request or treatment and communicates them to health care team so steps can be taken to eliminate or minimize delays. UR/CDI nurse will utilize condition code 44 guidelines when appropriate UR/CDI nurse will perform admission, concurrent, and discharge reviews using Milliman Care Guidelines to facilitate medical necessity. UR/CDI nurse will send clinical information to payers as requested/required. UR/CDI nurse will facilitate peer to peer reviews for inpatient medical necessity denials with attending physician. UR/CDI nurse will monitors all patients for medical necessity taking necessary action to include issuing ABN’s or HINN’s and appropriately document. Performs other duties as assigned by supervision.Qualifications:
Education:â— RN licensure required. (Bachelor’s preferred).
â— BLS required.
Training and Experience:â— 3-5 years clinical experience preferred
Job Knowledge:â— Knowledge of Conditions of Participation for Utilization Review
â— Knowledge of compliant query practices.
â— Demonstration of effective problem-solving techniques including conflict management skills
â— Demonstration of excellent oral and written communication skills
â— Excellent organizational and record-keeping skills, as well as the ability to manage multiple cases
â— Completes responsibilities in a timely manner through effective organization, setting priorities, delegation, and time management skills
â— Maintains integrity, confidentiality, and ensures compliance with WRMC’s policies and procedures, regulatory and legal requirements and current health care standards.
Essentials:
Must be able to report to work fit for duty and free of any adverse effects of illegal drugs, medical marijuana, prescription medication, and/or alcohol. Must be able to effectively communicate both orally and in writing with other individuals.Physical Demands: Job responsibilities require a considerable amount of physical work. The individual will be required to assist with lifting and moving patients, pushing of carts, wheelchairs, and other equipment; and lifting or pushing of up to 50 pounds. The individual must be able to bend over to perform certain duties, e.g.., check chest tube drainage, check urinary output, etc. The individual must also be able to maneuver throughout the halls, stairways, and patient rooms in response to hospital emergencies. Interpretation of environmental input requires visual and auditory skills. A significant amount of writing and computer entry is required.