Utilization Case Manager Jobs in Michigan (NOW HIRING)

JOB SUMMARY
Under the general supervision, The RN Case Manager facilitates the achievement of optimal patient outcomes within appropriate length of stay and utilization resource parameters. Works collaboratively with the medical staff, nursing and ancillary departments to develop an effective plan for patient transition to home or to other post-acute care services. Strives for superior performance by consistently providing service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. As a customer-focused Memorial Healthcare team member he/she must be accessible, flexible, knowledgeable and responsive.
JOB SPECIFICATIONS
EDUCATION: RN required. Must be licensed to practice in the State of Michigan. Bachelor's degree in a health related field or required to obtain a Bachelor's in a health related field within 3 years of accepting the position.
EXPERIENCE: Three (3) years of clinical experience in a short term acute care hospital setting. Prior Case Management or utilization review experience preferred. Case Management certification preferred.
ESSENTIAL PHYSICAL REQUIREMENTS: Must be able to sit or stand for long periods of time; be able to travel independently within the organization, including crowded or confined areas; ability to do reaching, bending, lifting and pulling. At minimum, 75% of time spent on the job will require standing or ambulating.
ESSENTIAL MENTAL ABILITIES: Must be able to complete an assessment of a patient's medical status and develop and appropriate plan with identified discharge needs. Must be able to retrieve, interpret and utilize information and data from multiple sources. Must be able to work effectively in situations involving high stress, interruptions and deadlines. Must be self-motivated and able to work independently. Must be able to independently prioritize work for efficiency and timeliness of completion.
JOB RESPONSIBILITIES
1. Utilizes appropriate data, tools and resources to identify patient needs, issues and treatment goals.
2. Collaborates with the Medical Staff, nursing, ancillary departments, patient and family to establish an effective discharge plan for transition to home or post-acute care services.
3. Completes appropriate internal and agency referrals to mobilize the resources required for safe discharge to home (i.e. Home Health, Hospice, DME, infusion services, etc.).
4. Collaborates with post-acute care providers (i.e. Nursing home, rehabilitation, sub-acute care, etc.) to ensure an effective transition from the acute care setting.
5. Documents a complete and accurate assessment of the patient's post discharge needs, discharge plan, resource referrals, etc. in the medical record. Updates documentation as needed to reflect the most current plan.
6. Completes documentation of Medical Necessity of Admission for all patients requiring an inpatient, observation or extended recovery level of care. Utilizes severity of illness (SI)/intensity of service (IS) information as related to InterQual© criteria sets.
7. Refers cases to the Physician Advisor (PA) per established triggers/protocols and maintains PA decision documents.
8. Collaborates with patient's attending physician, PA, and other utilization review staff to appeal third party payer denials or RACs activities related to medical necessity of care.
9. Participates in all committees and performance improvement activities as assigned.
10. Serves as a case management resource expert for employees, the Medical Staff, patients and families.
11. Provides patient, family, employee and Medical Staff education as appropriate.
12. Demonstrate job related aspects of patient safety to assure a safe environment, safe and effective use of equipment and technology and decreased risk of potential adverse patient occurrence.
13. Demonstrate knowledge of and supports hospital and departmental mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.
14. Maintains current knowledge of standards, regulations, laws, etc. as related to department activities.
15. Perform all other related duties as assigned.