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Case Management Manager

Oversees utilization management, care coordination, and discharge planning for patients. Assesses, plans, implements, monitors, and evaluates the services and options available to meet individuals' health needs, using screening criteria, developed critical pathways, and available resources to promote quality cost effective care outcomes. Supports the physician and interdisciplinary team in facilitating patient care in order to enhance the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. Identifies areas where performance improvement is needed, such as daily workflow, education, process improvements, and patient satisfaction.: Contributes to profitability and growth through expansion activities in case management (CM) care management. Assists in the development strategy with implementation of strategic, high quality, CM care management customer-specific products. Assists in the development of short- and long-term case management strategies, objectives, and budgets. Serves as resource for other departments in solving problems relating to patients, physicians, providers, payers, vendors, and accounts. Assists in development of and implements departmental and company policies and procedures. Conducts analysis of quality and productivity auditing of staff and departmental workflows. Directly manages licensed staff in CM Department, including interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; and addressing complaints and resolving problems. Assists the Director in the development and management of the CM Department budget, including monitoring overtime and associated costs, submitting purchase orders for departmental supplies, recommending additional staff, and assisting with purchases and capital expenditures requiring higher level authorization.

Case Management Head

Directs and coordinates case management to assure quality cost effectiveness of high risk and high cost cases. : Develops guidelines for working with patients, health care management companies, insurance companies or other third party payers to determine quality cost effective care. Case coordination may include prospective and retrospective review that includes, but is not limited to, prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and ensuring quality cost effectiveness. Evaluates outcome of patient care. May arrange referrals, consultations, therapeutic services, and confer with other specialists on course of care and treatment.

Home Care Hospice Reimbursement Manager

Assures that all daily patient financial services functions are completed to ensure maximum cash flow, timely customer service with patient families and other staff, and compliance with all regulatory requirements of governmental agencies and third party payers. Manages and supervises the Patient Financial Services staff.: Manages the production of the initial monthly billing, the monthly revenue journals, and related reports for General Accounting. Assists Contract Services in the development of rates for specific facility, provider, payer, and physician contracts. Assists the Controller and the Director of Accounting with revenue rate projections for annual budget preparation. Investigates and evaluates changes in any government or third party payer regulation that may impact reimbursement. Assists in the development of standards and processes that promote effective and efficient operations in the Patient Financial Services area and related areas. Oversees the coordination of staff to maintain the timely flow of billing data, including insurance verifications, census reporting, production of billing, and collections. Acts as an educational resource for staff and management for reimbursement, billing compliance, and insurance issues. Manages resources, such as time, expenses, supplies, labor, etc., and develops staff resources through training, mentoring, coaching, etc. May participate with various organizations on a local or State level in relationship to hospice/health care reimbursement.

Home Care Team Manager

Manages the clinical coordination of care for a team of home care providers. Directs patient services as related to the plan of care and utilization management in compliance with State and Federal regulations. Assist clinical staff in developing an appropriate plan of care. : Ensures timely and appropriate documentation on the patient record. Coordinates and initiates involvement of organization's resources, such as Advanced Practice Nurses, Home Health Aides, Therapists, Social Workers, Dieticians, etc. Makes home visits as necessary to assist or instruct Staff Nurses and to aid in effective case management. Ensures the proper use and ordering of supplies. Provides follow-up to patients and/or primary caregiver as necessary. Participates in quality improvement initiatives. Oversees scheduling of interdisciplinary team. Participates in intake processes as needed. Engages in proactive customer service with patient/family, referral sources, and colleagues. Maintains confidential patient and/or agency information in accordance to HIPAA and agency policies. Participates in the hiring, orientation, training, evaluation, and continuing education of staff assigned to the team. May act as a liaison with managed care companies in obtaining authorization.

Home Care Nurse

Provides professional nursing care for assigned patients in their home. Evaluates, plans, and makes appropriate changes to the home care nursing process. Requires RN license.: Assesses the patient's condition and the home environment. Instructs patient and family members on health care.

Medical Nurse Home Care

Nurse Home Care

Ambulatory Nurse Case Manager

Works with enrollee's providers and caregivers in a health plan to provide intensive, comprehensive case management and increase efficient utilization of services. Typically requires Registered Nurse licensure with patient care experience. Certified Case Manager (CCM) certification may be required.: Identifies chronic or catastrophic cases through the case management process and initiates intensive case management according to program guidelines. Evaluates the medical necessity for elective inpatient hospital admission, and authorizes the admission along with the estimated length of stay. Consults with Inpatient Nurse Case Managers regarding existing case management enrollees as well as potential case management enrollees. Screens for the medical necessity of outpatient procedures, home medical equipment, medications, and any other service that requires precertification. Retrospectively reviews medical admission of categories of diseases and procedures. Makes recommendations for standards of care as necessary. Identifies quality indicators through the case management process. May direct abnormal lengths of stay to the Medical Director or Associate Medical Director. May perform on-site reviews for back-up to an Inpatient Nurse Case Manager.

Medicare Nurse Case Manager

Plans, directs, implements, and evaluates appropriate healthcare services for Medicare patients in conjunction with Physician's treatment plan to ensure that cost effective, quality care is provided. Typically requires licensure as a Registered Nurse with three years of relevant nursing and medical case management experience. Certification as a Case Manager or professional certification in a clinical specialty may also be required.: Coordinates cases that normally include prospective and retrospective review and prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and ensuring quality cost effectiveness. Develops a plan of care for Medicare patients from admission to discharge. Monitors patient progress toward desired outcomes through assessments and evaluations. Develops and administers education and prevention programs for Medicare patients. Analyzes referred cases for potential case management interventions. Evaluates the effectiveness of alternate care services and ensures that cost effective, quality care is maintained to meet case management objectives. Determines if proposed medical treatment plans meet contract provisions. May arrange referrals, consultations, therapeutic services, and confer with other specialists on course of care and treatment. May negotiate fees with providers of medical care, agencies, and outside vendors to achieve maximum cost effectiveness.

Nurse Case Manager (Mentor)

Plans, directs, implements and evaluates appropriate healthcare services in conjunction with the physician treatment plan to ensure that cost effective, quality care is provided.: Case coordination normally includes prospective and retrospective review which includes prior authorization, determining the appropriate level of care and utilization of services, concurrent review, retrospective review, developing discharge plans, and ensuring quality cost effectiveness. Develops a plan of care for patients from admission to discharge. Monitors patient progress toward desired outcomes through assessments and evaluations. Develops and administers education and prevention programs. Analyzes referred cases for potential case management interventions. Evaluates the effectiveness of alternate care services and ensures that cost effective, quality care is maintained to meet case management objectives. Determines if proposed medical treatment plans meet contract provisions. Authorizes initiation of medical case management. This position typically requires a licensed Registered Nurse with a minimum of five years of relevant nursing and medical case management experience. Certification as a case manager or professional certification in a clinical specialty may also be required. May arrange referrals, consultations, therapeutic services, and confer with other specialist on course of care and treatment. May negotiate fees with providers of medical care, agencies and outside vendors to achieve maximum cost effectiveness. May provide guidance to less experienced case managers.

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