GENERAL SUMMARY
The Case Manager - Utilization Review is responsible for coordinating the case management care plan to meet the individual/caregiver needs, promoting quality, cost-effective outcomes. Work involves identifying and resolving barriers that may hinder effective patient care and patient progression to a safe discharge in a timely manner. Responsible for the facilitation of clinically pertinent reviews on patient admissions for continued stay reviews including completion of certifications. Reports to department leadership.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Educates and empowers individual/caregiver toward self-care and independence.
Collaboratively works to carry out the process of assessment, planning, facilitation, care coordination, evaluation and advocacy options and services to meet the individual's and family's comprehensive health needs.
Assesses the patient's plan of care and develops, implements, monitors and documents the utilization of resources and progress of the patient through their care.
Interfaces with managed care organizations, external reviewers and other payers to ensure that the admission and continued stay are in compliance with CMS standards.
Facilitates options and services to meet the patient's health care needs.
Performs other duties as assigned.
LICENSES AND/OR CERTIFICATIONS
RN holding a current Virginia state license or valid Compact State license or Medical Social Worker (MSW).
Case management certification a plus.
MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS
Professional knowledge of area of responsibility in order to direct planning and implementation of individualized service plan for eligible children with special health care needs to include medical care, social, developmental, educational, vocational and financial aspects.
RN (BSN preferred) holding a current Virginia state license or valid Compact State license, with three years acute pediatric experience or a Medical Social Worker with an MSW degree required.
Will consider a qualified individual with a Bachelor's degree in a related field with 5 years of utilization review, case management and discharge planning experience in pediatrics.
One to three years case management/ care coordination experience preferred.
Must be able to plan, manage and establish a professional working environment within areas of responsibility.
Must possess the ability to identify problems and implement solutions for operational and organizational issues.
Interpersonal skills necessary in order to communicate effectively with other professionals.
Competence in use of personal computers, word processing, spreadsheets and database software.
Knowledge of utilization review processes necessary.
Must possess the verbal/writing skills to adequately describe the patient's clinical presentation and progress in a comprehensive and concise manner.
Demonstrates an understanding of the authorization process with Medicaid and other insurances as well as knowledge of Medicaid regulations.
WORKING CONDITIONS
Normal office environment with little exposure to excessive noise, dust, temperature and the like.
PHYSICAL REQUIREMENTS
Click here to view physical requirements. (https://www.chkd.org/uploadedFiles/Documents/Employees/Category%20A%20Jobs.pdf )
