Case Manager RN Job Description
Case manager RN
provides guidance and review third party (Medicare, Medicaid and managed care) budget process for facilities.
Case Manager RN Duties & Responsibilities
To write an effective case manager RN job description, begin by listing detailed duties, responsibilities and expectations. We have included case manager RN job description templates that you can modify and use.
Sample responsibilities for this position include:
Maintain a current knowledge base of federal (Medicare) and state (Medicaid) regulations
Interacting verbally with providers and patients in accordance with contract guidelines
Contribute to the development of patient-focused care and initiate the process in accordance with established guidelines
Perform pre-authorization, concurrent and retrospective reviews of Medicare/Medicaid/Commercial members
Abide by and support the care management programs in order to ensure quality and efficient clinical operations
Admits patients, develops and updates patient plan of care adhering to the Medicaid/Medicare criteria for home care provision
Identify complex, high-risk patients and proactively manage care including but not limited to care management planning, referral management, post-discharge planning, and coordinating transitional and community based care
Reviewing member plan of care to assure appropriateness of services being authorized and provided to members
Entering authorizations in CCMS to authorize the provision of services, specifically for a NCM RN visits, PT visits, and authorizations for DME
Conducting monthly integrated clinical assessments telephonically with members on case load to review current status and service provision and satisfaction with services provided
Case Manager RN Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Case Manager RN
List any licenses or certifications required by the position: CPR, BLS, PRI, CCM, AHA, CM
Education for Case Manager RN
Typically a job would require a certain level of education.
Employers hiring for the case manager RN job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Education, Graduate, School of Nursing, Management, Health, Science, Associates, Healthcare, Interdisciplinary
Skills for Case Manager RN
Desired skills for case manager RN include:
Regulations
Medicare
Nurse Practice Act
Care management
Managed care
Guidelines
Managed care rules
Managed care and PPS systems
Demonstrated competency in ensuring compliance with Medicare and third party reimbursement
Insurance benefits and cost management strategies
Desired experience for case manager RN includes:
Reviewing and updating care plans in accordance of needs of members on a monthly and on-going basis
Providing telephonic case management
Discharging planning needs at admission
Performing regular concurrent reviews on all patients
Coordinating all home care services needed to facilitate safe and timely discharge
Following selected patients in the outpatient setting
Case Manager RN Examples
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Case Manager RN Job Description
Job Description Example
Our company is searching for experienced candidates for the position of case manager RN. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for case manager RN
- Work with medical directors in interpreting appropriateness of care and accurate claims payment
- Manage appeals for services denied
- Conduct pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts
- Ensure member access to medical necessary, quality healthcare in a cost effective setting according to contract
- Facilitate member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications
- Conduct pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews
- Consult with clinical reviewers and/or medical directors
- Facilitate member care transition through the healthcare continuum
- Refer treatment plans/plan of care to clinical reviewers as required
- Provide, coordinate, and direct the provision of home nursing care according to physician's orders based on agency policies and procedures
Qualifications for case manager RN
- Travel 15% in Broward County, Florida
- Previous Case Management, Concurrent / Utilization Review, and/or Discharge Planning experience
- Supervise and evaluate Home Health Aides and Licensed Practical Nurses/Licensed Vocational Nurses
- Assess and evaluate patient's / client's status
- Review and revise assignment plan as necessary to meet the patient's needs
- Oversee assigned area
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Case Manager RN Job Description
Job Description Example
Our innovative and growing company is looking for a case manager RN. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for case manager RN
- Act as a resource for members of the healthcare ream along the continuum of care
- Conduct assessments, develop treatment plans, perform defined interventions, and generate referrals to providers
- Evaluate and pre-authorize request for inpatient/outpatient, specialty care, home care, Durable Medical Equipment, and transportation services
- Document all interventions and telephone encounters with providers, members, and vendors
- Developing a Plan Of Care that corresponds with the Physicians' orders through assessment of patient's needs, condition, and environment
- Consulting with other health team members at time of initial visit, updating plan of care regularly as necessary, and documenting this care following the agency's procedures
- Maintaining communication with Case Managers, Staff Coordinator and Director of Home Care Services
- Providing teaching and counseling both patient and family
- Providing skilled nursing care that conforms with Agency patient care and general medical policies
- Rotating weekend, night, and holiday call with staff to facilitate adequate coverage for all patients
Qualifications for case manager RN
- Participating in agency evaluation program as instructed
- Regularly conducting Case Care Conferences
- Abiding by and promotes Agency administrative policies
- Oversight of patient's discharge appeal process
- Identification and tracking of avoidable days
- Record communication in patient's medical record
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Case Manager RN Job Description
Job Description Example
Our growing company is looking for a case manager RN. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for case manager RN
- Work collaboratively with primary care health care professionals to offer individualized assistance with improving and maintaining quality patient care
- Monitoring and evaluating effectiveness of the care plan to ensure member/caregiver satisfaction with services
- Acting as a resource to staff in the planning and delivery of outstanding member care
- Maintaining oversight and communication with members and providers during inpatient acute, sub-acute and/or long-term admissions
- Completing documentation in computer database of all member care
- Providing individual and group education and support to members and their families as needed
- Assess and risk stratify members
- Act as a liaison between Claimants, Providers, External Claim Representatives, Clients and Attorneys, as needed
- Coordinating discharge needs and facilitating alternative level of care
- Maintaining ongoing communication with the attending Physician and ancillary providers regarding the patients needs
Qualifications for case manager RN
- 1+ year of previous Case Management experience in a Hospital setting
- Previous Meditech and Interqual experience
- Recent experience and be proficient with InterQual and MCG (formally Milliman)
- Documenting clinical information into Medical Management system
- Attending Team Meetings and Case Management meetings on a weekly basis
- Reviewing requests for specialty services and direct In Network, when available
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Case Manager RN Job Description
Job Description Example
Our company is looking to fill the role of case manager RN. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for case manager RN
- Practices and adheres to departmental and State guidelines
- Ensures compliance is maintained according to CMS standards
- Addresses staff, physician, patient, and family concerns immediately
- Reviewing patients' medical records and participating in direct and indirect communication with care givers to ensure continued appropriate level of acre, including the level of care of elective surgical cases
- Performing, consulting, and collaborating in activities related to the development of safe effective and efficient discharge or disposition of patients for an assigned patient caseload
- Ensuring medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, out of network services, and appropriateness of treatment setting and level of care
- Partnering with Physician Clinical Reviewers and/or Medical Directors to interpret appropriateness of care, intervention planning, and general clinical guidance
- Collaborating with providers to assess consumer needs for early identification of and proactive planning for discharge
- Conducting clinical assessment to develop goals that address individual needs in order to develop a care plan
- Psychosocial Management -- assessing and collaborating with social workers to address psychosocial needs including individual, familial, environmental
Qualifications for case manager RN
- At least 1 year of hospital based case management preferred
- Certification in Case Management or BS/BSN preferred
- Managed long-term care case management experience
- ASN and BSN
- Microsoft Office/Suite proficient (Outlook, Word, Excel, PowerPoint or Access)
- Inpatient nursing or related field
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Case Manager RN Job Description
Job Description Example
Our company is growing rapidly and is hiring for a case manager RN. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for case manager RN
- Monitor and evaluate effectiveness of the care management plan and modify as necessary
- Interface with Medical Directors and Physician Advisors on the development of care management treatment plans
- Conducting assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment
- Monitoring and evaluating effectiveness of the Care Management plan and modifying as necessary
- Interfacing with Medical Directors and Physician Advisors on the development of care management treatment plans
- May include phone contact with identified members or providers to explain the program, assess needs, educate regarding the disease as appropriate, instruct the member how to access the program resources, suggests and/ or arranges follow-up including mailing of educational materials, contact with community resources, facilitating physician visits , and documenting the re-contact into the web-based system depending on the needs assessment
- Will be working with clients enrolled in the home and community based waiver program
- Will be responsible for developing clients’ person centered service plan
- Communicates with patients, family, and other medical personnel in a timely fashion, as necessary, to facilitate a mutually desired outcome
- Uses sound clinical judgment in assessing appropriateness and effectiveness of medications to determine a medications use, dosage, and potential side effects on a case by case basis
Qualifications for case manager RN
- 2 -3 years of Case Management, Utilization Management, and/or Discharge Planning experience
- Knowledge of age appropriate resources within the community (Infants, Pediatrics, Adolescents, Adults, and Geriatrics)
- Develop a cost-effective plan that is acceptable to both patient and physician utilizing both DoD and community resources
- Current state Licensure in SW or RN (Compact RN - When a nurse changes primary state of residence by moving from one compact state to another, the nurse can practice in the new state on the former license for up to 90 days
- Current and valid license to practice as a Registered Nurse (ADN or BSN) in the state of Idaho
- Bachelor of Science in Nursing, Social Worker or equivalent