The Case Manager monitors, evaluates and assists in the maintenance and improvement of efficient utilization of hospital resources through performance of pre-admission/admission and continued stay medical record reviews. Intervenes to reduce and eliminate service delays and non-acute hospital days. Monitors the quality of documentation and services provided and makes recommendations for improvement. Review determinations include, but are not limited to:
- Compliance with regulatory, state and federal requirements.
- Medical necessity and appropriateness with use of medical ISD-A criteria.
- Services to be rendered are timely and performed in the most appropriate setting.
- Maximal benefit coverage via compliance with certification required.
- Managed care contract requirements.
Education Knowledge of utilization review standards and patient care practices normally acquired through completion of a nursing program.
Bachelor's Degree in Nursing preferred.
Experience Minimum of two years' acute care hospital experience.
Experience in critical care, general medical and/or surgical nursing, and experience in educational presentations beneficial, as well as previous experience in the application of Utilization Review activities and medical record reviews.
Required Possesses an active Wisconsin RN nursing license.
Other
Successful completion of Quality or Utilization Review certification examination desired.
Active membership in professional organizations (i.e., NAHQ, WAHO) beneficial.
Certification in Case Management desired.
Possesses general understanding and knowledge of:
Medicare system
MedStar initiatives
Utilization review principles and objectives
Managed care indicators
Quality Improvement principles and Risk Management objectives
Possesses and exercises good public relations skills.
Possesses strong clinical skills, assessment and good professional judgment, as well as broad-based knowledge of medical management, nursing management and medical terminology.
Demonstrates the ability to read and comprehend government regulations and contracts.
Demonstrates familiarity and knowledge of medical records organization and procedures.
