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RN Case Manager

Company: Mercy Health
Location: Fairfield
Posted on: November 22, 2022

Job Description:

Thank you for considering a career at Mercy HealthJob DescriptionCollaborates with physicians and clinical staff in initiation, development, coordination and integration of ongoing clinical assessment, patient care planning, patient teaching, assessment of patient progress through the continuum of care and evaluation of discharge requirements necessary for the achievement of determined outcomes. This responsibility is assumed within the context of appropriate allocation and utilization of resources and quality of care, collaborating with professional hospital and community disciplines to support the patient along the continuum of care.Screens patients for the appropriate level of care, for the determination of medical necessity and for discharge planning needs. Focuses on concurrent review on diagnosis, problems, procedures or practitioners with identified or suspected utilization/quality/risk related problems. Coordinates communications/reviews records on admission and concurrently. Keeps current regarding criteria and standards by which various review organizations make decisions for certification of medical necessity/quality of care and applies those during chart review. Assesses for discharge planning needs and follows through on all physician or staff referrals. Reviews admission and continued stays for patients in accordance to applicable state or federal law, regulations, or third party contractual requirements.Acts as a resource to members of the health care team regarding utilization or resources, quality of care, and clinical aspects of coding. Understands and follows state, federal, and county regulations, prospective payment systems, and managed care organizations, changes in the health care industry in addition to standards of medical and nursing practice. Provides ongoing education to the nursing staff regarding utilization/documentation issues through both informal and formal discussions. Maintains communication and cooperative relationships with all disciplines, identifying potential barriers to efficient utilization of quality of care and makes recommendations to facilitate progression of care. Interacts or directs interaction regarding observation vs. admission status of patients. Participates in progression of care conferences, as appropriate. Maintains contact with and assists physicians to further identify and assess utilization variances and advises on appropriate documentation. Directly or indirectly participates in the patient/family teaching plan.Represents the facility, physicians and patients in matters of denial payments and appeal of denials as appropriate. Assists physicians with correspondence regarding denial activity when appropriate. Cooperates with insurance reviewers to facilitate certified days and provide additional information if patient stay is denied.Functions as liaison internally and externally. Is knowledgeable of all local community, city, and state resources and serves as a resource for others. Makes appropriate referrals to local community, city, or state agencies for services needed, serving as a patient advocate and maintaining patient rights and safety. Provides referrals for services indicated by screening and assessment. Serves as a resource to in-house patients and families, interdisciplinary staff, the community, and physicians, and participates in hospital committees as appropriate. Maintains a current provider list to include home health agencies, durable medical equipment companies, hospice and extended care, and rehab facilities.Ensures accurate, consistent and concurrent documentation for insurance and other data elements in the appropriate case management computer tools.Mercy Health is an equal opportunity employer.Many of our opportunities reward* your hard work with:Comprehensive, affordable medical, dental and vision plansPrescription drug coverageFlexible spending accountsLife insurance w/AD&DEmployer contributions to retirement savings plan when eligiblePaid time offEducational AssistanceAnd much more*Benefits offerings vary according to employment statusScheduled Weekly Hours:40Work Shift:DaysDepartment:Case Mgmt - Fairfield HospitalAll applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health - Youngstown, Ohio or Bon Secours - Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employer, please email recruitment@mercy.com. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com

Keywords: Mercy Health, Fairfield , RN Case Manager, Executive , Fairfield, Ohio

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