Case Manager Full-time
20 days ago
Miami
Job Description Job Summary: Seeking an experienced case manager with +5 years of experience in an acute hospital setting. Qualifications: • Experience, • 5+ years of experience in managed care, • Substantial clinical experience, • Education, • Bachelor's degree (required), • Masters (preferred), • Licensing, • Foreign Medical Graduate or Registered Nurse (preferred), • CCM (Certified Case Manager) (preferred), • ACM (Accredited Case Manager) (preferred), • Bilingual (English/Spanish) (preferred) Responsibilities: • Performs and documents patient assessment within 24 hours of admission, • Checks prior authorizations initiative by admitting, • Knowledge navigating and using payer portals, • Performs concurrent reviews, • Contacting all HMO’s on a daily basis and provides clinical information to obtain insurance authorization for the patient’s admission and continued stay, • Indicates the appropriate level of care and utilization of services needed, • Establishes criteria for medically necessary services, • Knowledgeable of Milliman Care and Interqual Guidelines, • Develops a plan of care for patients from admission to discharge., • Promotes the most efficient and cost-effective use of services, • Curtails the performance of inappropriate and/or duplicate services, • Encourages standardization of medical practice patterns, • Enhances the quality of healthcare, • Performs concurrent reviews for patients to ensure that extended stays are medically justified and are documented in patient's medical records., • Calculates and manages the lengths of stay and continued-stay days for patients., • Evaluating the patient’s condition and readiness for discharge planning, • Develops discharge plans, • Communicate and assist the physicians in the planning and coordination of patients discharge planning, • Management of transfer procedures, • Management of the guardianship process, • Able to discuss and educate patient/family regarding discharge planning and resources available after discharge. Clearly specifies all the information discussed with the patient and/or family regarding the patient’s discharge plan., • Participates in PI programs through the identification of opportunities for improvement, data collection, evaluation of findings, improving the process, applying knowledge and incorporates into practice, • Scheduling Peer-to-Peer reviews with payors, • Proactively identifying and resolving issues that could lead to denials Skills: • Familiarity with Medhost electronic medical records, • Extensive medical knowledge, • Self-driven (work and education), • Keeps knowledge up to date by reading literature and participating in outside continued education meetings, training, and conferences, • Working knowledge of regulatory agencies, • Excellent human relations and communication skills (verbal and written) to maintain good rapport and effective working relationships with medical staff, nursing staff, and other ancillary department staff throughout the hospital, • Excellent organizational skills and attention to detail, • Ability to convey care plan to physicians and the medical team, • Proficient with Microsoft Office Suite or related software.