Registered Nurse (RN) - Case Management
Surgery Partners
Addison, TX

Manager - Case Management, Full-Time (Onsite)

GENERAL SUMMARY OF DUTIES: The case management team at Methodist Hospital for Surgery works as a facilitator rather than a provider of patient services. Case management consists of utilization review and discharge planning. Utilization review ensures that the patient is receiving the level of care that is medically necessary and in the correct setting. Discharge planning consists of preparing for the patient's care as the patient moves from one level of care to another. REQUIREMENTS: * RN license required * BSN required; CCM strongly preferred * Minimum of 5 years of previous case management experience is required in a hospital setting * Understands the importance of teamwork when achieving desired results * Understands basic CMS guidelines and has experience working with payor specific medical policies and reimbursement methodologies * Understands how to use InterQual or Milliman to determine the appropriate level of care * Understands basic coding principles and chargemaster operations * Ability to be assertive with persuasive communication skills; action oriented * Ability to be organized and efficient with time * Ability to be compassionate to people and their situations to work with them in a positive way that will help them make positive forward strides * Critical thinking skills, decisive judgment, and the ability to work with minimal supervision while meeting firm deadlines * Communication skills necessary to be a good listener and speak in an understandable way * Previous supervisory experience preferred ESSENTIAL FUNCTIONS: * Supervises a small staff which includes assigning, reviewing, and evaluating their work. * Manages the utilization review process prospectively by reviewing authorizations for correct type of stay; concurrently by managing the correct level of care in the correct setting; and retrospectively by managing and appealing claims that have been denied * Manages the discharge planning process to ensure that the patients move to the appropriate level of care after discharge * Understands medical and reimbursement policies and regulations relevant to the hospital's larger payers * Communicates those policies to surgeons, clinicians, and non-clinicians in a timely manner PHYSICAL DEMANDS: * The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. * While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus. * The employee must be able to lift and/or carry 15 pounds on an occasional basis and be able to push/pull 5 pounds on an occasional basis. * The employee must be able to stand and/or walk at least five hours per day WORK ENVIRONMENT: * The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.