Job Summary: Seeking an experienced case manager with +5 years of experience in an acute hospital setting. Qualifications: • Experience • 5+ years of experience in managed care • Substantial clinical experience • Education • Bachelor's degree (required) • Masters (preferred) • Licensing • Foreign Medical Graduate or Registered Nurse (preferred) • CCM (Certified Case Manager) (preferred) • ACM (Accredited Case Manager) (preferred) • Bilingual (English/Spanish) (preferred) Responsibilities: • Performs and documents patient assessment within 24 hours of admission • Checks prior authorizations initiative by admitting • Knowledge navigating and using payer portals • Performs concurrent reviews • Contacting all HMO’s on a daily basis and provides clinical information to obtain insurance authorization for the patient’s admission and continued stay • Indicates the appropriate level of care and utilization of services needed • Establishes criteria for medically necessary services • Knowledgeable of Milliman Care and Interqual Guidelines • Develops a plan of care for patients from admission to discharge. • Promotes the most efficient and cost-effective use of services • Curtails the performance of inappropriate and/or duplicate services • Encourages standardization of medical practice patterns • Enhances the quality of healthcare • Performs concurrent reviews for patients to ensure that extended stays are medically justified and are documented in patient's medical records. • Calculates and manages the lengths of stay and continued-stay days for patients. • Evaluating the patient’s condition and readiness for discharge planning • Develops discharge plans • Communicate and assist the physicians in the planning and coordination of patients discharge planning • Management of transfer procedures • Management of the guardianship process • Able to discuss and educate patient/family regarding discharge planning and resources available after discharge. Clearly specifies all the information discussed with the patient and/or family regarding the patient’s discharge plan. • Participates in PI programs through the identification of opportunities for improvement, data collection, evaluation of findings, improving the process, applying knowledge and incorporates into practice • Scheduling Peer-to-Peer reviews with payors • Proactively identifying and resolving issues that could lead to denials Skills: • Familiarity with Medhost electronic medical records • Extensive medical knowledge • Self-driven (work and education) • Keeps knowledge up to date by reading literature and participating in outside continued education meetings, training, and conferences • Working knowledge of regulatory agencies • Excellent human relations and communication skills (verbal and written) to maintain good rapport and effective working relationships with medical staff, nursing staff, and other ancillary department staff throughout the hospital • Excellent organizational skills and attention to detail • Ability to convey care plan to physicians and the medical team • Proficient with Microsoft Office Suite or related software. • Integrity https://casemanagementstudyguide.com/which-case-management-certification-is-best/