MSW or Case Manager

Title: MSW or Case Manager
Location: Mount Vernon, WA 98273
Duration: 13 weeks
Shift: 8-12 hrs depending on department location (inpatient unit 8 hrs, CVH 10 hrs, SVH ED 12 hrs)
Minimum Years of Experience: 1

Essential Functions:
Conducts and documents medical necessity reviews that demonstrate delivery of reasonable, necessary, and appropriate (according to evidence based clinical standards of practice) patient care.
Collaborates with contracted resources for external medical necessity reviews and audits.
Documents Changes of Status (COS) and completes supporting paperwork.
Performs readmission assessments utilizing indicated focus study.
Assists with insurance requests for clinical reviews and continued stay authorizations. Provides physician education on medical necessity criteria.
Participates in medical necessity audits.
Assists with non-Medicare appeals research and preparation of written correspondence.
Facilitates Medicare discharge appeal process through contracted Quality Improvement Organization (QIO).
Participates in family care conferences as needed.
Captures potentially avoidable days (PADs) and documents in designated system.
Collaborates with physicians, nursing, social work, and other disciplines, departments, payers, and agencies to eliminate barriers to an efficient transition through the care continuum.
Collaborates with discharge planning team, and assists in the facilitation of discharges as needed. Supports Population Health initiatives through patient outreach activities as assigned.
Adheres to regulatory agency guidelines/requirements governing patient notification (ie Important Message from Medicare, Medicare Outpatient Observation Notice, Hospital-Issued Notice of Non-coverage).
Complies with all SRH Policies and Procedures.
Performs other duties as assigned by Manager or Designee.

Education:
BSN required unless a Certified Case Manager (CCM), or 2 years equivalent experience.
Experience/Training Minimum three (3) years clinical practice experience required.
Previous utilization review experience strongly desired.
Experience using medical necessity screening criteria preferred.

License/Certifications:
Current Washington State RN License required.
Certified Case Manager (CCM) or Certified Professional in Healthcare Management (CPHM) preferred.