Nurse Case Manager - AIS - Woodbridge, NJPosted: November 12, 2009
Nurse Case Manager - AIS - Woodbridge, NJ Tracking Code 204455-005 Job Description JOB SUMMARY: The role of the case manager is to collaborate with patients by assessing, facilitating, planning and advocating for health needs on an individual basis. Successful outcomes are achieved by positive relationship building, effective written and verbal communication, ability to effect change, perform critical analysis, plan and organize effectively and promote client/family autonomy. It is crucial for the case manager to understand the benefits, additional funding resources, clinical standards, cost benefit analysis and outcomes. The physical and psychological aspects must be evaluated to have the end result in a positive outcome. MAJOR DUTIES AND RESPONSIBILITIES: Performs a comprehensive assessment through communication with the patient and the healthcare provider to determine the degree of injury and disability and the proposed treatment plan. The treatment plan is evaluated by using the Care Paths for soft tissue injury and determined criteria. Pre-certification of referred claims from contracted auto insurance carriers by determining medical necessity and applying the Care Paths for specific diagnoses Imputing the demographics, date of loss, nature of claimants injury, treating providers and treatment plan in the electronic medical record. Three-point contact is made with the patient, the claim adjuster and the treating, provider within 24-48 hours of notification of loss to establish a treatment plan. Provider contact includes confirming functionality, degree of injury, proposed treatment plan and exploring the ability to return to pre injury status. The case manager will assist the patient and provider in planning, implementing and coordinating the proposed care. The initial physical assessment is reviewed for medical necessity to determine the appropriate level of treatment and duration. Patient contact includes discussion of injury, treatment received, past medical history, current medical treatment and psychosocial supports. The case manager is a patient advocate and is to insure that the patient is educated regarding the process of treatment. Accurate documentation in the Diary of the date of contact with the claimant and provider with explanation of the pre-certification process. Adherence to the Care Paths for the diagnosis with documentation of the clinical findings to support the treatment plan. ICD-9 and CPT codes should be obtained from the provider. The time frame and the number of treatments approved are to be documented in the treatment plan. Make recommendations of alternatives to the treatment plan when appropriate to providers of service. The alert date is to be entered in the diary for follow up. When medical necessity cannot be identified, refer to the physician advisor with sufficient information to support intervention with the treating physician. Document all activities in the electronic medical record. For inpatient admissions, contact the hospital to obtain the clinical information and apply guidelines. Recommend changes in the level of care and/or alternatives to inpatient stay when appropriate. Develop individual case management plans through assessment, planning and implementation of the treatment plan and coordinate discharge needs. Establish and maintain contact with the hospital utilization staff, discharge planners and physicians and act as a liaison to coordinate and identify goals for the injured party. Negotiate rates with out of network providers to provide the appropriate level of care and monitor cost savings. For inpatient admissions perform concurrent review to make certain the care is medically appropriate in accordance with guidelines. Assist hospital with the discharge plan and refer to a Field Case Manager for continuity of care. Coordinate discharge plan with the Field Case Manager and assist in implementation of the plan. Maintain contact with the patient, family members and medical providers to assure appropriate case management services within the full continuum of care. Assist with obtaining additional resources when needed. Identify potential quality of care issues and service issues. Refer to the Quality Assurance Department when appropriate. Ensure the integrity and completeness of utilization documentation and data by using audit tools to verify accuracy. Communication with the payer either electronically or verbally based on the contractual agreement. Required Skills QUALIFICATIONS: Registered Nurse - Licensed in the jurisdictional state Previous case management experience dealing with PIP, Workmans Compensation, managed care, home care or rehabilitation Knowledge of computers, windows 98 Excellent verbal and written communication skills, including conflict management Problem solving skills and independent decision making skills Job Location Woodbridge, NJ, US. Position Type Full-Time/Regular
Please refer to job code concentra-204455 when responding to this ad.
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