St. Joseph’s Healthcare System is recognized for the expertise and compassion of its highly skilled and responsive staff. The combined efforts of the organization’s outstanding physicians, superb nurses, and dedicated clinical and professional staff have made us one of the most highly respected healthcare organizations in the state, the largest employer in Passaic County, and one of the nation’s “100 Best Places to Work in Health Care”.
Responsible for the coordination and implementation of systems and services leading towards an organized, multidisciplinary team approach to patient care management. Provides clear communication across the continuum to improve patient outcomes. Assures quality, cost-efficient care for an identified patient population through the continuum of care. Develops and coordinates efforts to reduce clinical resource utilization by working closely with physicians, nursing staff and other hospital personnel. Reviews medical records for appropriateness of admissions, continued stay and level of care changes against criteria of severity of illness and illness of service to ensure optimal reimbursement to the hospital.
Essential Job Functions Assesses the patient's clinical, psychosocial, emotional, cultural and medical status. Identifies needs and develops a plan of care that addresses those needs. Works with the multidisciplinary team to establish a complete discharge plan (primary and secondary). Identifies risk factors and makes referrals to appropriate disciplines. Educates and interacts with physicians. Reviews all medical records within one business day to certify admission and continued stay based on established criteria. Consults with Physician advisor when issues arise. Coordinates: home care, sub-acute care, acute rehab, snf, infusion, medical equipment. Refers to government and community programs, as needed. Understands clinical resource management, utilization management, throughput and prevention of denials concurrently. Monitors LADs/certifications. Documents timely as per policy; plan of care, discharge plan including contact names, telephone numbers and authorizations. Evaluates monthly variance data: LOS, DRG, Nursing Unit, Denials, avoidable days and formulates a plan to decrease variances. Maintains competency in case management by inter-rater reliability, literature, contact hours (CEUS) and participates in departmental PI projects. Maintains competency in case management by inter-rater reliability, literature, contact hours (CEUS) and participates in departmental PI projects. Appeals & Denials Responsibilities: Supports concurrent denials review process by working with the NCM to avoid denials and process recoveries by assisting in case review. Demonstrates expertise in writing appeals through medical necessity criteria, follows three level appeal process and obtains timely payer responses to appeals. Coordinates all activities related to denials management: concurrent review, appeals, on-site reviews, Medicare, Medicaid and self pay. Keeps accurate documentation of Medicaid certifications, 7-day readmissions, Medicare denials, knowledge of regulatory requirements/seeks guidance when necessary. Accurately and consistently maintains data tracking elements of denials, recoveries, and appeals. Reviews and analyzes monthly reports for trends; reports to Director. Provides support to Care Management staff as it relates to utilization, concurrent review and discharge planning. Participates in audits including Medicaid, Department of Health, No Fault. Protects and keeps safe all patient information: verbal, written or electronic. Provides ongoing education for NCMs, SWs, CMAs, MDs, nurses and other hospital staff about clinical denials management, medical necessity and avoidable strategies. Meets all required competencies for department, unit and/or hospital. Responsible for performing all other duties as assigned. Special Projects
Work requires the knowledge of theories, principles, and concepts normally acquired through completion of a Bachelor's degree in Nursing or closely related field and two to three years of work related experience. Managed care, home care, discharge planning or case management experience is strongly recommended. Case Management Society of America Certification CCM preferred. Licensure required as a Registered Nurse by the State of New Jersey.