RN-Case Management Job Description
Rn-case management
provides for continued stay reviews for patients, which meet the case management criteria, reviewing for intensity of service and meeting of discharge screens using Interqual standards.
RN-Case Management Duties & Responsibilities
To write an effective rn-case management job description, begin by listing detailed duties, responsibilities and expectations. We have included rn-case management job description templates that you can modify and use.
Sample responsibilities for this position include:
Coordination of the activities of the Case Management team including determining work procedures ensuring overall departmental effectiveness
Perform concurrent and retrospective utilization review using Interqual criteria to assure that the appropriate level of care is maintained throughout the patient’s hospital stay
Provide coordination of complex discharge planning needs and referrals to appropriate support services
Responsible for defining and directing a complete Case Management Program in conjunction with corporate goals and objectives
Minimum of 5 years of work experience in managed care and acute care settings with complex case management
Coordinate clinical operations to ensure compliance with Medicare and Managed Care requirements
Focuses on the integrated function of utilization review and discharge planning of the hospitalized patient
Performs discharge planning by assessing the patient’s needs
The Director of Case Management is responsible for the day to day operations of the department
The Director is responsible for coordinating and facilitating multiple resources, internal and external, into a unique and single approach to care coordination for each patient assigned case management services
RN-Case Management Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for RN-Case Management
List any licenses or certifications required by the position: BLS, CPR, HCA, CCM, ACM, BSN, RN, CCCTM
Education for RN-Case Management
Typically a job would require a certain level of education.
Employers hiring for the rn-case management job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Education, Management, Graduate, School of Nursing, Nursing Program, Associates, Healthcare, Nursing Education, Science
Skills for RN-Case Management
Desired skills for rn-case management include:
Workers' compensation laws and regulations
McKesson's InterQual SI/IS Criteria
Medicare
Case management
InterQual criteria
Medi-cal regulations
Discharge planning
Case Management process
Excel
Pharmaceuticals
Desired experience for rn-case management includes:
Ensuring accurate workflows and quality of work in the disease management area
Analyzing data for cost and utilization of high risk members
Providing oversight for aggressive outreach to our membership
Facilitate requests for Sub-Acute care, DME, Home Health Care and Transportation for MAPD members
Alert Provider Relations team regarding possible need to negotiate rates for Non-Par Providers, assure that all necessary paperwork is obtained and entered into the member file
Participate in IDT meetings as appropriate
RN-Case Management Examples
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RN-Case Management Job Description
Job Description Example
Our growing company is searching for experienced candidates for the position of rn-case management. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for rn-case management
- Developing, implementing and analyzing quality improvement activities and outcomes of the department which includes but is not limited to monthly Clinical Revenue audits as defined by Corporate Case Management
- Four (4) years’ experience in case management
- Accessing and analyzing all processes on an ongoing basis to determine their effectiveness, eliminate inefficiencies and make recommendations to senior management to improve workflow, operations, and staff performance
- Coordinating activities between clinical programs, communication, and report requirements to maintain operational efficiencies and to be in compliance with the Department of Labor (DOL), Summary Plan Description (SPD) departmental protocols and clinical policies and procedures
- Interacting and collaborating with other departments
- Staff development, clinical orientation, ongoing education, and training programs to meet the changing needs of the Department
- Continually assessing clinical staff performance against internal and external departmental and industry standards
- Performs admission certification screening for patients in accordance with Utilization Plan using ISD criteria, and performs concurrent stay reviews at least every 72 hours for medical necessity using ISD criteria
- Supporting supervisory duties of clinical and support staff
- Quarterly audits of clinical staff
Qualifications for rn-case management
- 5+ years of related experience with 3+ years of experience in an Adult, Acute Care setting (Medical-Surgical, Emergency Room, Critical Care)
- Previous Pain Management or Workers' Compensation experience
- Bachelor’s Degree in Nursing, Business or Health Care Administration or equivalent years of work experience required
- Working knowledge of Milliman / InterQual guidelines or other regulatory protocols
- Performs special
- 5 years’ experience in a healthcare-related field
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RN-Case Management Job Description
Job Description Example
Our company is searching for experienced candidates for the position of rn-case management. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for rn-case management
- Provide case management service to a select group of assigned patients in accordance with department standards, policies, and procedures
- Develop unit based mechanisms in conjunction with nurse manager and case management to communicate anticipated discharge dates and involve case managers in identifying patients who are off guideline or have additional needs
- Investigation and resolution of clinical claims related issues
- Supporting departmental training and clinical quality improvement activities
- Ongoing staff development
- Assisting in expediting work delays
- Promoting a decrease in length of stay
- Improving the quality patient care
- Expanding the facilities use of outside resources, , nursing facilities, rehab centers, and sub-acute facilities
- Works with complex cases, promotes the delivery of quality
Qualifications for rn-case management
- 5 years’ experience with broad clinical experience
- 3 years’ direct supervisory experience or demonstrated supervisory experience leading teams in a matrix management environment
- Inpatient CM/UM experience and management experience
- Strong knowledge of functional tasks performed within department
- Knowledge in the principles of risk management and quality assurance
- Knowledge of NCQA standards
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RN-Case Management Job Description
Job Description Example
Our company is growing rapidly and is hiring for a rn-case management. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for rn-case management
- The Director is accountable for the compliance and efficiency measures of the Case Management functions and personnel within the UM Department for all lines of business and all functional areas
- Oversees complex case management and special needs population interventions and other Facey-wide clinical activities focused on management of over and under utilization of services using a set of metrics and industry standards
- Will spend no less than seventy-five percent of time providing direct case management activities on the phone, face to face, e-mail or other interactive methods
- Organizes, integrates and modifies the resources necessary to accomplish the goals set forth in the case management plan
- Monitors the ongoing process by gathering sufficient information from all relevant sources about the case management plan and its activities and determine the plans effectiveness
- Evaluates case managements effectiveness in reaching desired outcomes and goal and makes modifications or changes in the case management plan based on the evaluation
- Participates as educator and resource person for provider offices and hospital staff as it pertains to the health plan case management policy and procedures
- Will spend no more than Twenty-five percent of time coordinating and monitoring non direct case management activities and administrative activities
- Demonstrates knowledge of NCQA Complex Case Management requirements and evidence-based guidelines and where to locate the most effective guideline
- The Director will develop, implement, and review the Utilization Management Plan annually
Qualifications for rn-case management
- Knowledge of State Mandates and Regulations
- Knowledge of regulatory bodies and their processes
- Professional certification in a clinical specialty as appropriate to the business unit
- Knowledge of Plan products, applications, policies, procedures and systems
- Associate's Degree and professional nursing license (Required) current and valid in state of practice
- Associate Degree, Diploma in Nursing required from an accredited institution
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RN-Case Management Job Description
Job Description Example
Our innovative and growing company is hiring for a rn-case management. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for rn-case management
- The Director will provide leadership, communication, and supervision to the department staff to ensure company and facility strategy is operationalized and adherence to applicable policies
- Evaluating patient care data to ensure that care is provided in accordance with clinical guidelines and organizational standards
- Seeking treatments that balance clinical and financial concerns with the family's needs and the patient's quality of life
- Manage department operations to assure effective throughput and reimbursement for services provided
- Lead the implementation and oversight of the hospital Utilization Management Plan using data to drive hospital utilization performance improvement
- Ensure medical necessity review processes are completed accurately and in compliance with CMS regulations and Tenet policy
- Ensure timely and effective patient transition and planning to support efficient patient throughput
- Implement and monitor processes to prevent payer disputes
- Develop and provide physician education and feedback on hospital utilization
- Ensure compliance with state and federal regulations and TJC accreditation standards
Qualifications for rn-case management
- BSN from an accredited institution preferred
- At least two years of acute hospital experience
- Critical Care of Emergency department experience
- Proficiency in the daily use of standard office equipment such as computer, phone, fax, pager, copier and skill in utilizing Microsoft Word and Outlook tools
- Significant knowledge and understanding of availability of community and post-acute resources and related payer requirements
- 2 years Director or Supervisor experience preferred
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RN-Case Management Job Description
Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of rn-case management. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for rn-case management
- Completes initial and annual competency and evaluation review on all case management staff
- Develops action plan for case managers that fail to meet the IRR acceptable “match” rate to ensure improvement in the accurate application of InterQual criteria
- Monitors case management processes and staff productivity to ensure medical necessity reviews are completed timely and accurately, payer communications are sent and authorizations or denials documented and followed up, and that transition planning assessments are completed timely
- Participates as educator and resource person for provider offices and hospital staff as it pertains to the health plan case management and utilization management policy and procedures
- Demonstrates knowledge of NCQA Complex Case Management requirements, evidence-based guidelines, where to locate the most effective guideline, and utilization management requirements
- Knowledgeable of NCQA Standards, Commercial requirements, BCBS IL IPA requirements, Medicaid and Medicare requirements, other product requirements, associated department policies for processes, medical necessity, and language requirements
- Develops and submits budget assumptions, capital and annual budgets for the department
- Initiates activities to enhance revenue and support cost reduction as evidenced by managing department costs as well assisting all departments in providing the appropriate, medically necessary services to our patient population
- Participates in selecting outside sources for needed services when resources are not available with the hospital
- Participates in community organizations, meetings, and events representing CTMC
Qualifications for rn-case management
- Clinically competent in areas of responsibility
- Must have InterQual experience
- Must have Utilization Review experience preferably in an acute care setting
- Must have Case Manager Experience
- Must have NCCPA/AANP
- Ability to efficiently communicate with physicians, customers, and employees, both in person and by telephone