Dual Care Manager (RN) - Case Mgmt.
University of Maryland Medical System
Foster Care Case Manager Job in Largo, MD
What You Will Do:
Dual Care Manager - Care Mgmt.
Full-time - Evening Shift
Dual Care Management Role:
Under general supervision, provides utilization review and discharge assessment, denials management for an assigned patient assignment. This role utilizes nationally recognized care guidelines/criteria to assess the patient's need for acute inpatient care as well as the appropriate level of care. The role requires interfacing with the Care Management team (RN/SW), medical team, other hospital staff, physician advisors and payers; while also includes. assessing, develops, implements, coordinates and monitors care plans for the inpatient/observation population facilitating patient movement throughout the continuum of care to include patient admissions and discharges; both within the treatment facility and into the community. Provides leadership support within the multi-disciplinary teams to achieve quality clinical outcomes.
The following statements are intended to describe the general nature and level of work being performed by staff assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
Performs timely and accurate utilization review for all inpatient and OBS admissions using nationally recognized care guidelines/criteria relevant to the payer and documents in the EMR and shares review with the payer for authorization.
Performs timely and accurate continued stay reviews for all inpatients using nationally recognized care guidelines/criteria relevant to the payer and documents in the EMR and shares review(s) with payer for continued stay authorization.
Communicates with care management team, physician advisor, medical team and payors as needed regarding reviews and pended/denied days and interventions.
Supports concurrent appeals process through proactive identification of pended/denied days. Implements the concurrent appeals process with appropriate referrals and documentation, escalates to Care Management Leadership team and Physician Advisor.
Ensures appropriate Level of Care and patient status for each patient (Observation and Inpatient).
Reviews tests, procedures and consultations for appropriate utilization of resources in a timely manner.
Conducts CMS HINN discussions and issuance of CMS HINN Letter.
Notification to Patient regarding Observation status and issuance of MOON form.
Issuance of Medicare Important Notice Notification
Documents Avoidable Days
Ensures Regulatory Compliance related to Utilization Management conditions of participation and standing Utilization Policy and Procedure
Assures appropriate reimbursement and stewardship of organizational and patient resources by timely reviews, documentation and sending reviews to payers, reviewing monthly denials to avoid future denials.
Pursues and reports opportunities to improve documentation of severity of illness and intensity of care for accurate reimbursement.
Remains current on clinical practice and protocols impacting clinical reimbursement.
Assesses needs of the patient and identifies patient choice for next level of care and coordinates safe and appropriate discharge plan based on patients' individual needs.
Develops innovative and creative discharge planning activities in collaboration with the patient care team.
Collaborates in continuous quality improvement initiatives including referral of appropriate cases to Quality and Risk Departments using UMMSafe reporting process.
Attends management team meetings as required, 8am Care Management Huddle.
All other duties as assigned
What You Need to Be Successful:
Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required.
Bachelors in Nursing required.
Preferred: Master's Degree in Nursing
Two years' experience in acute care.
One year of experience in case management
One year of experience in case management or utilization management with knowledge of payer mechanisms and utilization management is preferred.
ED/ICU background preferred.
Willing to train the right nurse
We are an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.