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RN-Coordinator Case Management - Per Diem

Philadelphia, PA, US, 19104

Job Type: 

Req ID: 617

Shift: Days

Employment Status: AX - Active - Per Diem 

Job Summary

Under the general supervision of the Director, the Case Manager provides clinically-based support to the delivery of effective and efficient patient care.  Paces each case from physiological and economic perspectives.  Has overall accountability for the utilization management and transition management for patients within the assigned caseload.   Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement.  Uses criteria to confirm medical necessity for admission and continued stay.  With the patient, family and health care team, creates a discharge plan appropriate to the patient’s needs and resources.

Job Responsibilities

         Essential Duties and Responsibilities:

  1. Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information.   Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation.   Documents all case management interventions  in the current electronic system (EPIC).
  2. Validates admission and continuing stay criteria with third party payers as well as the Attending Physicians.  Recommends alternative care sites where appropriate. 
  3. Collaborates with third party payers to prevent denial of payment and proactively addresses issues contributing to a potential denial.  Intervenes to prevent the denial when possible.
  4. Supports the effective prevention and management of denials, including providing requested information as part of the appeal process.
  5. Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team.   Uses knowledge of usual length of stay to initiate a plan for discharge.
  6. Collaborates and communicates with patients/families related to reimbursement issues and to create a discharge plan.   Supports the process of patient choice in establishing a discharge plan.
  7. Uses clinical knowledge and knowledge of anticipate response to treatment to assess patient progression towards anticipated outcomes.  Communicates and coordinates with the patient/family and health care team to intervene when progression is stalled or diverted.  Addresses actual/potential barriers to discharge
  8. Completes the interventions necessary for discharges to home with self-care, home with services or  short term skilled nursing facility placement.  Assembles necessary referrals, discharge summaries and pertinent information for  discharge to home,placement, or transfer  prior to the day of discharge. 
  9. Actively contributes to, participates in, and follows through on interventions identified in care coordination and complex patient rounds.
  10. Identifies high risk patients and creates a collaborative plan to address their unique needs.

Required Licenses, Certifications, Registrations

Registered Nursing License in The Commonwealth of Pennsylvania (Active)

Required Education and Experience

  • Nursing Diploma required. BSN preferred.
  • Minimum of three (3) years experience as clinical nurse in an acute care pediatric setting required.

Preferred Education, Experience & Cert/Lic

  • Previous experience with discharge planning or home care experience preferred.
  • Prior experience as a Case Manager or Utilization Reviewer preferred.

Additional Technical Requirements

  • Excellent communication skills and demonstrated organizational skills.
  • Ability to work effectively with all departments and all levels of CHOP professionals.
  • Ability to work independently or within a team structure.
  • Must be very organized and able to work independently.
  • Ability to establish priorities among multiple needs, meet deadlines and maintain standards of productivity.
  • Knowledge of managed care admission process (i.e. verification of benefits, admissions notification).
  • Ability to effectively negotiate with internal and external providers of patient care services.
  • Sound problem solving skills.
  • Excellent customer service orientation and strong interpersonal skills.
  • Computer skills and a working knowledge of Word, Excel and Access.

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