Case Manager Nurse
Core
Plans care for targeted patient populations, manages resources and denials, and facilitates discharge planning and transitions to post-acute care.
Role type
Senior Case Manager Nurse (Utilization Management)
Builds
Post-acute care transitions and discharge plans for assigned patient caseloads
Domain
Healthcare / Utilization Management / Case Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Registered Nurse licensure, discharge planning, utilization management, denial management, care coordination, post-acute referrals, resource management, clinical documentation, payer regulations knowledge, medical necessity determination
Preferred skills
Bachelor of Science in Nursing (BSN)
Technologies
Electronic health records, quality screens
Responsibilities
Manage transition/discharge planning for assigned patients; Collaborate with multidisciplinary teams to facilitate patient transitions; Monitor patient progress and intervene to ensure high-quality, cost-effective care; Provide education to staff, physicians, patients, and families; Assess patient needs and develop individualized transition plans; Initiate and facilitate referrals to post-acute services (Homecare, Hospice, Rehab, Skilled Nursing); Screen for appropriate authorization and level of care; Apply utilization criteria to ensure medical necessity of admissions and stays; Facilitate covered day reimbursement certification and resolve payor issues; Educate staff on payer regulations to prevent denials; Complete clinical reviews for patients; Assist patients/families with advance directives and medical power of attorney.
Seniority
Mid-level, hands-on IC