Care Management Nurse-RN
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WellSpan Health
Chambersburg, PA, US
Summary
The Care Management Nurse performs utilization reviews to ensure medical necessity and coordinates patient care transitions within a team model. They also facilitate discharge planning and act as a liaison between the treatment team and third-party payers.
Job Description
General Summary
Performs a variety of duties and applies utilization and care management techniques to determine the most efficient use of resources to support the provision of appropriate, cost effective and quality health care. Works in a team type assignment or Care Coordination Team (CCT) Model (Care Manager and Social Worker teams are assigned to patients by physician practice) to address patient care transition needs. Provides leadership in the integration of utilization and care management principles throughout the hospital.
Responsibilities
Duties and Responsibilities
- Performs initial reviews for medical necessity and appropriateness of setting for the assigned case load.
- Conducts concurrent reviews to ensure medical necessity for continued hospitalization and initiates problem-solving techniques as needed to prevent over and/or under utilization.
- Liaisons between third party payers and the treatment team regarding the identified treatment plan in accordance with contractual guidelines or System policy.
- Assists the patient care team with the identification and coordination of alternative treatment settings which will provide appropriate care, maintain quality of care and reduce cost.
- Identifies conditions which require care management across the continuum. Collaborates with the members of the patient care team to identify interdisciplinary needs.
- Makes arrangements for discharge needs (DME, Home Health, IV antibiotics, etc.) in collaboration with patients, families and care team as needed.
- Assists with the collection and analysis of utilization patterns and denied cases.
- Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the attention of the appropriate manager(s).
- Prepares and maintains appropriate documentation as required.
- Maintains established policies and procedures, objectives, quality assessment and safety standards.
- Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
- Performs other related duties as identified.
- WellSpan Health has adopted and implemented a compliance program to support WellSpan's values and standards for professionalism, integrity, and ethics. Expected to support and meet the values and standards of the organization and the performance expectations of the job, the department, and the compliance program.
- WellSpan Health has adopted and implemented a privacy program to safeguard the patient information and the business and operational information of the organization. Expected to support and meet the values and standards of the organization to safeguard patient and business/operational information.
The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.
Qualifications
Qualifications
Minimum Education:
- Associates Degree Required
Work Experience:
- 2 years Recent acute care experience. Required
- Utilization management, care management, or clinical nursing specialty. Preferred
Licenses:
- Licensed Registered Nurse Upon Hire Required or
- Registered Nurse Multi State License Upon Hire Required and
- Basic Life Support Upon Hire Required
Knowledge, Skills, and Abilities:
- Excellent interpersonal/communication skills.
