Case Manager

Location
North Carolina, United States
Posted
20 Nov 2018
End of advertisement period
20 Jan 2019
Ref
101001142
Contract Type
Permanent
Hours
Part Time

DRH-CARE MANAGEMENT

Job Description

UTILIZATION MANAGER

Work Schedule Details:

Position requires 10h/shift on alternating w/e (2 full weekends per month) and 8h shift per week x 3, totaling 64 hrs. per month.

Duties & Responsibilities:

  • Validates authorization for all bedded patients.
  • Validates commercial payer authorization within the contractual timeframe at time of presentation, every third day or as needed ( e.g. ED, Direct Admit, Transfers).
  • Manage concurrent cases to resolution care that may impact payer approval to authorize care as medically necessary Partner with Revenue Cycle team to support resolution of retrospective denials.
  • Coordination of review with third party reviewers.
  • Manage retrospective review process. Conducts initial review and continued stay reviews as designated in UM plan.
  • Reviews records for medical necessity and collaborates with physician (s) and members of the care team to validate information.
  • Establishes and communicates estimated LOS using GMLOS.
  • Utilizes InterQual Level of Care Criteria as a guide to support medical necessity determinations.
  • Refers cases with failed criteria to Physician Advisor and appeals as necessary.
  • Collaborates withCM, SW, Physicians, and Care Team to enhance communication related to discharge planning and utilization management.
  • Ongoing collaboration with Case Manager to ensure that patient?s condition meets medical necessity criteria and communicate changes that could affect the discharge plan of care.
  • Confirms that orders reflect the patient?s level of care utilizing established criteria.
  • Partners with internal and external Physician Advisors, as well as Compliance and with Revenue Cycle partners, within the health system to provide a safeguard processes and expected outcomes.
  • Provides formal and informal education to physicians and the healthcare team to improve processes and outcomes related to utilization review and compliance with utilization management plan.
  • Provides feedback as requested to enhance negotiations with payors.
  • Develops and maintains positive relationships with customers internal and external to Duke Health System.
  • Maintains effective communication with health care team members related to care coordination and utilization management.
  • Contributes to a positive working environment and performs other duties as assigned/directed to enhance the overall efforts for the organization. Actively participates in a hospital committee
  • Works collaboratively with physicians, staff and service line leadership on quality and performance improvement activities related to optimal utilization of resources, efficient delivery of high quality care, patient flow, capacity management and other clinical cost reduction initiatives.

Requisition Number 101001142
Location Durham
Duke Entity DUKE REGIONAL HOSPITAL
Job Code 5013 CASE MANAGER
Job Family Level G1
Exempt/Non-Exempt Exempt
Full Time / Part Time PRN
Regular / Temporary Regular
Shift First/Day

Minimum Qualifications

Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status. 

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values. 

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.

Education

BSN or MSW required

Experience

3 years of relevant experience

Degrees, Licensures, Certifications

Requires ACM or CCM certification within 3 years of hire or by December 31, 2017 for current employee. BSN must have current or compact RN licensure in the state of North Carolina. MSW must have a current North Carolina license as a CMSW within 90 days of hire or a current license as an LCSW.

Auto req ID

106020BR