Case Management-RN

Job Details

Job Location:

Artesia, NM 88210

Position Type:
Full Time Education Level: Bachelors Degree Salary Range: $34.92 - $55.34 Hourly Job Shift: Any Job Category:
Nursing

• Servant Leadership – Leading by serving others with compassion and humility.
• Excellence – Striving for the highest quality in all we do.
• Respect – Treating everyone with dignity and kindness
• Virtuousness – Acting with honesty, integrity, and accountability.
• Innovation – Embracing new ideas to improve care and outcomes.
• Community – Fostering collaboration to meet the needs of those we serve.
• Education – Promoting learning and professional development.

• Directs the daily operations of case management, utilization management, discharge planning, social services, and care transitions.
• Establishes department goals, workflows, performance expectations, and accountability measures.
• Provides supervision, coaching, education, and performance evaluation for case management and social services staff.
• Ensures adequate coverage for utilization review, discharge planning, payer communication, and high-risk patient needs.
• Determines Patient medical eligibility, qualifying diagnosis, and determines Medicare/Managed Care eligibility based on skilled services provided
• Develops, reviews, and maintains departmental policies and procedures.
• Promotes effective communication and collaboration among case management staff, nursing, physicians, ancillary departments, and hospital leadership.
• Assists with departmental budgeting, staffing, productivity, and resource allocation.
• Identifies and plans strategies to reduce in-patient length of stay and resource consumption.
• Provides patient/ family with information about home health care, skilled nursing facilities, rehabilitation facilities and appropriate providers.
• Maintains availability to the patient/family as a resource to facilitate communication among providers and to monitor services rendered.

• Oversees the consistent and appropriate application of MCG guidelines for admission, level-of-care, continued-stay, and discharge-readiness reviews.
• Ensures MCG criteria are used as a clinical decision-support tool and not as a substitute for physician judgment, applicable regulations, payer requirements, or the patient’s individual clinical circumstances.
• Reviews inpatient, observation, and outpatient cases to support appropriate patient-status recommendations.
• Ensures timely initial and concurrent reviews, payer notifications, authorizations, and clinical updates.
• Escalates cases that do not clearly meet MCG criteria or require additional physician documentation.
• Collaborates with attending physicians and hospital leadership regarding inpatient versus observation status.
• Facilitates secondary physician review or physician-advisor review when medical necessity or patient status remains unclear.
• Supports compliance with the Medicare Two-Midnight Rule and other applicable CMS patient-status requirements.
• Ensures required Medicare notices are delivered accurately and timely, including the Medicare Outpatient Observation Notice and other applicable beneficiary notices.
• Monitors the use of MCG and identifies educational needs, inconsistent application, and workflow gaps.
• Maintains staff competency in the hospital’s current licensed MCG content and documentation requirements.

• Reviews admissions and continued stays for medical necessity, intensity of service, severity of illness, and appropriate level of care.
• Identifies cases at risk for incorrect status, noncoverage, delayed authorization, or denial.
• Communicates medical-necessity concerns promptly to physicians and appropriate hospital leaders.
• Facilitates status changes when supported by the patient’s clinical condition, physician order, regulatory requirements, and hospital policy.
• Monitors short inpatient stays, extended observation stays, avoidable admissions, and potentially preventable readmissions.
• Ensures that patient-status determinations and changes are properly documented and supported in the medical record.
• Collaborates with health…