Care Management Nurse-RN - Care Management - Day

Duties and Responsibilities

• Performs initial reviews for medical necessity and appropriateness of setting for the assigned case load.
• Conducts concurrent reviews to ensure medical necessity for continued hospitalization and initiates problem-solving techniques as needed to prevent over and/or under utilization.
• Liaisons between third party payers and the treatment team regarding the identified treatment plan in accordance with contractual guidelines or System policy.
• Assists the patient care team with the identification and coordination of alternative treatment settings which will provide appropriate care, maintain quality of care and reduce cost.
• Identifies conditions which require care management across the continuum. Collaborates with the members of the patient care team to identify interdisciplinary needs.
• Makes arrangements for discharge needs (DME, Home Health, IV antibiotics, etc.) in collaboration with patients, families and care team as needed.
• Assists with the collection and analysis of utilization patterns and denied cases.
• Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the attention of the appropriate manager(s).
• Prepares and maintains appropriate documentation as required.
• Maintains established policies and procedures, objectives, quality assessment and safety standards.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Performs other related duties as identified.
• WellSpan Health has adopted and implemented a compliance program to support WellSpan's values and standards for professionalism, integrity, and ethics. Expected to support and meet the values and standards of the organization and the performance expectations of the job, the department, and the compliance program.
• WellSpan Health has adopted and implemented a privacy program to safeguard the patient information and the business and operational information of the organization. Expected to support and meet the values and standards of the organization to safeguard patient and business/operational information.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.