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About the Role

Responsible for managing a participant’s successful transition from hospital to home or other care setting, including overall care management, discharge planning, and quality of care. Manages post-acute care for high-risk participants to prevent poor health outcomes, frequent emergency room visits, and hospital readmissions. Reviews, recommends, and authorizes services based on medical necessity criteria.

Responsibilities

• Collaborates with hospitals, medical providers, caregivers, participants, families, team members, and payors to develop and implement safe discharge plans.
• Works with Nursing Home Staff and the IDT to develop and implement services to reduce hospital readmissions or ED visits.
• Participates in team meetings for interdepartmental collaboration with patients and families.
• Completes discharge assessments and follow-up phone calls in a timely manner.
• Provides care management services across sites and collaborates with team members, facilities, and discharge planners during transitions between care settings.
• Documents services in accordance with CLHC standards and federal/state regulations.
• Collaborates with PCP, specialty providers, and IDT regarding participant condition changes to coordinate resources for optimal care.
• Reviews acute and subacute rehab requests based on evidence-based medical necessity criteria.
• Recommends and contributes to improvements in services, programs, policies, and procedures.
• Assists with quarterly updates to provider HR-HI panels.
• Participates in provider HR-HI panel case reviews.
• Communicates HR-HI review recommendations to providers and the IDT.
• Processes authorization requests from in-network providers and communicates decisions.
• Collects, reviews, and evaluates information to make prospective, concurrent, and retrospective decisions using clinical criteria.
• Suggests alternate care plans, makes recommendations, and coordinates with the Provider/IDT for appropriate service utilization.
• Documents case reviews, communications, and outcomes in the electronic case file.
• Presents cases to the site Physician and/or Medical Director for review and determination.
• Ensures timely medical review of specific cases meeting decision turnaround time standards.
• Participates in inter-rater reliability testing on medical necessity criteria application.
• Refers potential quality of care concerns to Quality Management.
• Maintains confidentiality of all information in compliance with State and Federal Law and CenterLight Healthcare policy.
• Identifies and communicates system improvements or individual care issues that could impede appropriate care or service requirements.
• Performs other duties as assigned.

Requirements

• Minimum of three to five (3 - 5+) years’ experience in a hospital or home care clinical setting.
• Knowledgeable about Medicare and Medicaid guidelines.
• Individuals must be able to sustain specific physical requirements essential to the job.
• Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools.
• Must be able to visually assess patients, read orders and type/write documentation accurately.
• Must be able to listen attentively and document information from patients, community members, providers, etc., with accuracy.
• Must be able to speak comfortably and clearly with language motor skills for customers to understand.
• Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

Skills

• Case Management
• Discharge planning
• Utilization Review
• Typing
• Use of medical supplies
• Use of equipment

Location

• Alabama
• California
• Colorado
• Connecticut
• Florida
• Georgia
• Illinois
• Louisiana
• Massachusetts
• New Jersey
• New York
• North Carolina
• Ohio
• Oklahoma
• Oregon
• Pennsylvania
• Puerto Rico
• South Carolina
• Texas
• Utah
• Virginia
• Wisconsin

Work Type

• Full-time

Experience Level

• 3-5+ years

Education Level

• BSN required

Salary/Compensations

• $100,000.00 - $115,000.00

About the Company

• CenterLight Healthcare System currently hires employees in states where we are registered to do business.

Equal Opportunity

• We are an affirmative action and equal opportunity employer.
• All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information.
• We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.