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.
- 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.
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.