Employment Status: AF - Active - Regular - Full Time
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.
Essential Duties and Responsibilities:
* 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).
* Validates admission and continuing stay criteria with third party payers as well as the Attending Physicians. Recommends alternative care sites where appropriate.
* 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.
* Supports the effective prevention and management of denials, including providing requested information as part of the appeal process.
* 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.
* 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.
* 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
* 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.
* Actively contributes to, participates in, and follows through on interventions identified in care coordination and complex patient rounds.
* Identifies high risk patients and creates a collaborative plan to address their unique needs.
Job Responsibilities (Continued)
* Adheres to established departmental policies, procedures, and objectives.
* Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
* Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
* Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards apprpriate to this position.
* Demonstrates a courteous and professional manner through interactions with internal and external customers.
* Integrates scientific principles and research based knowledge in decision making.
* Exemplifies a professional image in appearance, manner and presentation.
* Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
* Reseraches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
* Adapts behavior as needed to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style
* Performs other related duties as assigned.
Job Responsibilities (Continued)
Required Licenses, Certifications, Registrations
RN license in the state of Pennsylvania
Required Education and Experience
Required Education: Nursing Diploma
Required Experience: Five (5) years' experience.
Preferred Education, Experience & Cert/Lic
Preferred Education: BSN
Preferred Experience: Previous experience with discharge planning or home care experience.
Prior experience as a Case Manager or Utilization Reviewer.
Previous experience in a pediatric setting or similar adult setting
Preferred Licenses/certificates/registrations: CCM or ACM Certifications
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.
All CHOP employees who work in a patient building or who provide patient care are required to receive an annual influenza vaccine unless they are granted a medical or religious exemption.
Children's Hospital of Philadelphia is committed to providing a safe and healthy environment for its patients, family members, visitors and employees. In an effort to achieve this goal, employment at Children's Hospital of Philadelphia, other than for positions with regularly scheduled hours in New Jersey, is contingent upon an attestation that the job applicant does not use tobacco products or nicotine in any form and a negative nicotine screen (the latter occurs after a job offer).
Children's Hospital of Philadelphia is an equal opportunity employer. We do not discriminate on the basis of race, color, gender, gender identity, sexual orientation, age, religion, national or ethnic origin, disability or protected veteran status.
VEVRAA Federal Contractor/Seeking priority referrals for protected veterans. Please contact our hiring official with any referrals or questions.
CHOP Careers Contact
2716 South Street, 6th Floor
Philadelphia, PA 19146
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* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.