<p>A Brief Overview Provides Case Management coverage for all points of entry to assure appropriate patient status reviews have been completed. Communicates and works effectively with others to achieve departmental objectives. Works flexible work schedules to provide Case Management coverage 16 hours/7 days a week. What you will do Performs initial patient status review. <em>Screens ED patients for admission criteria (medical necessity/patient status/level of care). </em>Communicates results of screening to attending physician if orders do not reflect level of care. <em>Communicates results of screening to bed control/registration team. </em>Utilizes Escalation Process as needed. <em>Coordinates delivery of HINN (Hospital Issued Notice of Noncoverage) when appropriate. </em>Documents initial screening criteria in patient care system (i.e. Cerner Powerchart or Rev Cycle). Provides medical necessity and level of care screening for Special Procedures/Cardiac Catherization lab/Operating Room conversions. <em>Conducts medical necessity and level of care screening. </em>Reviews chart or orders for appropriate order status. <em>Utilizes Escalation Process as needed. </em>Documents criteria review in patent care system (i.e. Cerner Powerchart or Rev Cycle). <em>Conduct Prospective reviews by assessing clinical information for medical necessity. </em>Submit initial clinicals to insurance companies for appropriate level of care approval and update applicable authorizations. <em>Conduct concurrent reviews by monitoring ongoing patient care to assess for level of appropriateness and sending additional clinicals as applicable. Facilitates continuity of care and makes referrals as appropriate to other services which includes but not limited to: </em>Social Work <em>Financial Counselor </em>Physician Advisor <em> Community Resources Confers with and works collaboratively with medical/hospital staff, in compliance with iRESPECT standards and promoting patient/customer satisfaction. To maximize operational efficiencies and outcome the Case Manager will focus on the following metrics: </em>Decrease in denials based on level of care <em>Decrease in patient status errors </em>Decrease in one and two day stays <em>Decrease in 72 hour readmissions </em> Increase in Patient/Physician satisfaction Maintains confidentiality of information in accordance with HIPAA/compliance policies and procedures. Prepares and maintains required logs, reports, records and files for administrative and compliance purposes within established timeframes. Updates patient information and documents patient status and screening review. Utilizes computer systems to enter and retrieve data. Maintains professional credentials and education necessary to keep abreast and maintain a current knowledge of clinical/theoretical principles, concepts and techniques, and current trends. Completes required continuous training and education, including department specific requirements. Works flexible schedule and provides coverage for relief and absences as required to ensure that Case Manager is present 16 hours/7 days a week. Qualifications Bachelor#s Degree Or equivalent experience in nursing Required and Education, training or experience to work with the adolescent, adult and/or geriatric patient population as assignment dictates Required RN - Registered Nurse - State Licensure and/or Compact State Licensure Registered nurse licensure to work in state of TN Upon Hire Required and CPR - Cardiac Pulmonary Resuscitation Upon Hire Required or BLS certification Upon Hire Required Minimum 3 years experience Three (3) years of clinical nursing experience in an acute care hospital, ambulatory care setting and/or managed care organization Required and Case management experience Preferred Physical Demands Standing - Constantly Walking - Constantly Sitting - Rarely Lifting - Frequently Carrying - Frequently Pushing - Occasionally Pulling - Occasionally Climbing - Occasionally Balancing - Occasionally Stooping - Frequently Kneeling - Frequently Crouching - Frequently Crawling - Occasionally Reaching - Frequently Handling - Frequently Grasping - Frequently Feeling - Constantly Talking - Constantly Hearing - Constantly Repetitive Motions - Constantly Eye/Hand/Foot Coordination - Constantly Regional One Health is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.</p> <p>A Brief Overview</p> <p>Provides Case Management coverage for all points of entry to assure appropriate patient status reviews have been completed. Communicates and works effectively with others to achieve departmental objectives. Works flexible work schedules to provide Case Management coverage 16 hours/7 days a week.</p> <p>What you will do</p> <ul> <li>Performs initial patient status review. <em>Screens ED patients for admission criteria (medical necessity/patient status/level of care). </em>Communicates results of screening to attending physician if orders do not reflect level of care. <em>Communicates results of screening to bed control/registration team. </em>Utilizes Escalation Process as needed. <em>Coordinates delivery of HINN (Hospital Issued Notice of Noncoverage) when appropriate. </em>Documents initial screening criteria in patient care system (i.e. Cerner Powerchart or Rev Cycle). </li><li>Provides medical necessity and level of care screening for Special Procedures/Cardiac Catherization lab/Operating Room conversions. <em>Conducts medical necessity and level of care screening. </em>Reviews chart or orders for appropriate order status. <em>Utilizes Escalation Process as needed. </em>Documents criteria review in patent care system (i.e. Cerner Powerchart or Rev Cycle). <em>Conduct Prospective reviews by assessing clinical information for medical necessity. </em>Submit initial clinicals to insurance companies for appropriate level of care approval and update applicable authorizations. * Conduct concurrent reviews by monitoring ongoing patient care to assess for level of appropriateness and sending additional clinicals as applicable. </li><li>Facilitates continuity of care and makes referrals as appropriate to other services which includes but not limited to: <em>Social Work </em>Financial Counselor <em>Physician Advisor </em>Community Resources </li><li>Confers with and works collaboratively with medical/hospital staff, in compliance with iRESPECT standards and promoting patient/customer satisfaction. To maximize operational efficiencies and outcome the Case Manager will focus on the following metrics: <em>Decrease in denials based on level of care </em>Decrease in patient status errors <em>Decrease in one and two day stays </em>Decrease in 72 hour readmissions * Increase in Patient/Physician satisfaction </li><li>Maintains confidentiality of information in accordance with HIPAA/compliance policies and procedures. </li><li>Prepares and maintains required logs, reports, records and files for administrative and compliance purposes within established timeframes. Updates patient information and documents patient status and screening review. Utilizes computer systems to enter and retrieve data. </li><li>Maintains professional credentials and education necessary to keep abreast and maintain a current knowledge of clinical/theoretical principles, concepts and techniques, and current trends. Completes required continuous training and education, including department specific requirements. </li><li>Works flexible schedule and provides coverage for relief and absences as required to ensure that Case Manager is present 16 hours/7 days a week. </li></ul> <p>Qualifications</p> <ul> <li>Bachelor's Degree Or equivalent experience in nursing Required and </li><li>Education, training or experience to work with the adolescent, adult and/or geriatric patient population as assignment dictates Required </li><li>RN - Registered Nurse - State Licensure and/or Compact State Licensure Registered nurse licensure to work in state of TN Upon Hire Required and </li><li>CPR - Cardiac Pulmonary Resuscitation Upon Hire Required or </li><li>BLS certification Upon Hire Required </li><li>Minimum 3 years experience Three (3) years of clinical nursing experience in an acute care hospital, ambulatory care setting and/or managed care organization Required and </li><li>Case management experience Preferred </li></ul> <p>Physical Demands</p> <ul> <li>Standing - Constantly </li><li>Walking - Constantly </li><li>Sitting - Rarely </li><li>Lifting - Frequently </li><li>Carrying - Frequently </li><li>Pushing - Occasionally </li><li>Pulling - Occasionally </li><li>Climbing - Occasionally </li><li>Balancing - Occasionally </li><li>Stooping - Frequently </li><li>Kneeling - Frequently </li><li>Crouching - Frequently </li><li>Crawling - Occasionally </li><li>Reaching - Frequently </li><li>Handling - Frequently </li><li>Grasping - Frequently </li><li>Feeling - Constantly </li><li>Talking - Constantly </li><li>Hearing - Constantly </li><li>Repetitive Motions - Constantly </li><li>Eye/Hand/Foot Coordination - Constantly </li></ul> <p>Regional One Health is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.</p>