The Case Manager is responsible for ensuring that patients are admitted and transitioned to the appropriate level of care. Works closely with the health care team to develop an affective plan of care. The Case Manager concurrently plans for transitions of care, discharges and post discharges following with community resources. The Case Manager coordinates with the patient, family, physicians, healthcare team as well as insurance plans. The Case Manager is also responsible for utilization and financial management of the patient during their hospital stay.

Essential Duties and Responsibilities:

• Performs admission reviews within next business day and concurrent daily for appropriateness of setting, documentation, plan of treatment, over/under utilization, delays of treatment of service.
• Responsible for ensuring that patients are admitted and transitioned to the appropriate level of care.
• Possess good organizational skills.• Communicates effectively with Physicians, patients, families and insurance companies.
• Works closely with the health care team to develop an effective care plan for the patient.
• Coordinates with the patient, family, physicians, healthcare team as well as insurance plans.
• Works closely with the insurance company monitoring payments, reimbursement and other transactions.
• Work closely with the OR Scheduler and Insurance Verifier to ensure patients are placed in the appropriate setting and admission is medically necessary.
• Notifies administration when assistance is needed regarding inappropriate admission or plan of treatment.
• Attends multidisciplinary team meetings to enhance continuum of care.
• Works closely with the coder and biller to ensure appropriate documentation is generated for billing.
• Possess knowledge of benefit plans, reimbursements and regulatory requirements.
• Conducts regular reviews of medical records to assure that services are being used appropriately.
• Possess knowledge of screening criteria as presented against the documented medical record with respect to patient needs.
• Verifies coverage and benefits with the insurance companies to assure the hospital is appropriately paid.
• Maintains liaison with social services in making appropriate referrals to facilitate continuity of care.
• Eliminates avoidable days and reduces readmission.
• Notifies patients about insurer’s decisions regarding medical necessity and ensures that the patient receives a Hospital issued notice of non-coverage if necessary.
• Performs other duties as assigned.

Education and Experience:

• RN Licensure in the State of Texas, required
• Bachelor’s degree preferred
• Minimum of three years’ experience as Case Manager