A Nurse Case Manager applies nursing expertise to coordinate a patient's medical care and provides advocacy to help them get the best and most affordable care. Develop care plans including discharge planning, coordinate delivery among providers, and teach patients and families how to follow the plan. They may also help patients navigate insurance and other healthcare bureaucracies and access related social services. May work with patients who have chronic illnesses or other complex medical needs. Works at a hospital or other healthcare facility; may follow patients throughout the span of their treatment.
Position Summary The Nurse Case Manager/Outpatient Coordinator is responsible for coordinating patient care across the continuum of care for acute, swing-bed, and outpatient services at Crook County Medical Service District (CCMSD). This position ensures appropriate utilization of services, discharge planning, regulatory compliance, utilization review, and efficient outpatient coordination. Essential Functions Acute Care Case Management Coordinates patient care from admission through discharge for acute care patients. Performs initial and ongoing discharge planning assessments. Collaborates with providers, nursing staff, therapy, and ancillary departments. Monitors length of stay and resource utilization. Assists with insurance verification and authorization as needed. Communicates with patients and families regarding discharge plans. Coordinates referrals to post-acute services. Swing Bed Case Management Coordinates swing bed referrals, admissions, and discharges. Ensures compliance with CMS Swing Bed Conditions of Participation. Verifies insurance, authorizations, and PASRR screenings when applicable. Coordinates interdisciplinary team (IDT) meetings. Tracks patient progress, length of stay, and discharge readiness. Communicates with referral sources, families, and providers. Maintains swing bed tracking logs and quality metrics. Outpatient Coordination Coordinates outpatient scheduling, order verification, and prior authorizations. Tracks Explanation of Benefits (EOBs) as applicable. Communicates insurance benefit information to patients. Coordinates with providers, registration, nursing, pharmacy and billing departments. Assists with patient navigation through outpatient services. Utilization Review Performs utilization review for acute and swing bed patients to ensure appropriate level of care. Reviews medical records for medical necessity and compliance with payer and CMS requirements. Collaborates with providers to obtain appropriate orders, documentation, and level-of-care determinations. Tracks and reports utilization review data, denials, and trends. Participates in utilization review committee meetings as assigned. Regulatory and Quality Responsibilities Ensures compliance with CMS Conditions of Participation and swing bed regulations. Assists with the development, review, and implementation of case management, swing bed, and utilization review policies to ensure regulatory compliance and effective care coordination across the continuum of care. Assists with quality improvement and utilization review activities. Maintains accurate and timely documentation.
Qualifications Education:
Registered Nurse Licensure:
Current Wyoming license BLS required CCM or ACM preferred.
Experience:
Minimum two years of clinical or case management experience preferred.
Skills:
Knowledge of CMS regulations, utilization review processes, strong organization, communication, and EHR proficiency. Physical Requirements Ability to sit, stand, and walk for extended periods. Occasional lifting up to 25 pounds. Ability to use standard office and computer equipment.
