Case Manager

Under the direction of the Director of Health Information, the Medical Case Manager (CM) is responsible for assessing, monitoring and evaluating services required to meet an individual's healthcare needs. Perform admission case and utilization review as well as continued stay review to ensure optimum utilization of resources, service delivery and compliance for Medicare, BCBS of MS and Federal, and all other assigned patients utilizing the InterQual intensity of service/severity of illness criteria.

JOB DUTIES/PERFORMANCE RESPONSIBILITES

Assess and reassess patients for medical necessity and appropriate setting. Patient assessment should be conducted within 24 hours of admission excluding weekends and holidays. Continued stay review is conducted regularly throughout the patient's hospitalization to assess the patient's need for continued inpatient treatment. Continued stay review will include provisions for identification of beneficiaries for whom other levels of care may be appropriate. Collaborate with physician/other health team members to improve both clinical and cost outcomes. Maintain effective communication with health care team members related to case management. Conducts admission, concurrent and retro- review procedures as required by payor. Assist Emergency Room physicians with appropriate admission status. Accept call pay for after hours and weekends to assist physician(s) with appropriate admission status. Maintain daily manual census to include both admit and discharge dates in concurrent order. Compiles and presents statistics to Utilization Review Committee. Notify physician of non-covered days, obtaining additional clinical information as needed. Report any non-compliance to director. Collaborate with the appropriate staff to issue denial notices if necessary. Provide concurrent review and follow-up with appropriate personnel regarding denials. Work with appropriate staff to develop processes to prevent denials and improve reimbursement. Provide feedback that will enhance negotiations with payors. Copy and review charts for completion before mailing in with compiling letters to payors for reconsideration in the appeals process for any denied days (all payors). Enter documentation of certification/authorization in computer system. Cross train with Surgical Case Manager. Assumes responsibility for special projects in department. Perform/assist with other duties as needed or assigned. Comply with all rules and regulations of the department and facility. Successfully completes competencies.