Utilization Management Case Manager PD

Responsible for the utilization management, quality assurance, and discharge planning activities for assigned services/areas/patients within Cottage Health.

Case management activities will result in quality outcomes, optimal care/cost management of services and/or procedures, a high level of customer satisfaction and contribution to an overall value-oriented experience of stakeholders and persons served.

This is not an exhaustive statement of duties, responsibilities, or requirements.

Employees will be required to perform any job, with related instruction given by their supervisor, subject to reasonable accommodation.

• Resource Management: Understand the principles of reimbursement and the services within the reimbursement parameters. Ascertain healthcare benefits utilizing both internal and external resources as appropriate to coordinate necessary and appropriate care, while appropriately preserving the healthcare benefits of the beneficiary. Identify and refer situations requiring immediate intervention to the attending physician, risk management, department director and/or physician advisor as appropriate. Refer cases not meeting criteria (including situations involving the timely provision of services) to the department director and/or physician advisor as appropriate. Maintain accurate and thorough documentation of resource management activities to include those mandated by third party payers and CottageOne medical record. (20%)
• Discharge Planning: On admission, initiative the coordination and development of a discharge plan. In conjunction with the healthcare team, patient, and family stakeholders identifies likely post-discharge needs. Provide appropriate information, education, and choice, making referrals as appropriate to implement the discharge plan (such as community resources, home healthcare, institutional placements, financial assistance, equipment needs, and/or alternative/specialized care settings). Facilitate the transfer of patients to other care facilities as appropriate. Maintain accurate and thorough documentation of discharge planning activities to include those mandated by third party payers and CottageOne medical record. (50%)
• Quality Assurance: Participate in the improvement of organizational performance through quality assurance and performance improvement activities. Participate in the tolls, measurement, and continuous improvement of quality, productivity, value, and efficacy of case management functions. Support system-wide development, analysis, and implementation of process improvement initiatives. Report suspected and/or emerging patterns and trends. Participate in the denial/appeal process as appropriate, and cooperate fully in all risk management activities and investigations. (10%)