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Job description
Company :
nAllegheny Health Network
nJob Description :
nGENERAL OVERVIEW:
nRegistered nurse who is proficient in the coordination of care and manages coordination of care in accordance with recognized standards of practice for Care Management. Professional role model utilizing expertise in care management to promote a collaborative professional environment that supports excellence of care and achievement of optimal resource utilization. Also facilitates appropriate LOS, patient satisfaction and reimbursement for all patients.
nESSENTIAL RESPONSIBILITIES:
nnnAssumes role in assessment of patient physical, psychosocial, and economic needs for effective transition of care planning to a variety of levels of care.
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nnIn collaboration with the care team, facilitates the development and communication of the continuum of care transition plan to appropriate health service providers.
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nnDocuments, verifies, and validates specific data required to monitor and evaluate interventions and outcomes. Interviews and collects patient specified data and chart review related to readmission.
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nnKnowledgeable of and complies with accreditation and regulatory requirements. Integrates performance improvement principles and customer service principles into all aspects of job responsibilities.
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nnObtains or ensures acquisition of appropriate pre-certification authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party guidelines. Obtains or facilitates acquisitions of urgent / emergent authorizations, continued stay authorizations and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements.
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nnDocuments, monitors, intervenes/resolves and reports clinical denials/appeals and retrospective payer audit denials. Collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor and third party payers.
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nnMaintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental commercial payer guidelines. Adheres to the policies, procedures, rules, regulations and laws of the hospital and all federal and state regulatory bodies. Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
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nnAssumes responsibility for AHN required continued education and own professional growth.
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nnPerforms other duties as assigned or required.
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n nQUALIFICATIONS:
n**** Minimum
nnnBachelor's Degree in Nursing -OR- Bachelor's Degree and Nursing Diploma -OR- 6 years of relevant experience in lieu of a degree
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nn3 years in a clinical nursing role
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nnCurrent State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
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nnCritical thinking and problem solving
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nnFlexibility and adaptability to change
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nnStrong communication and collaboration skills with ability to tailor style according to target audience (providers, peers, clinical team members, patients, families)
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n nPreferred
nnnNationally recognized Case Management Certification
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nnTransition planning and understanding of community and facility resources
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nnKnowledge of motivational interviewing techniques
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nnBSN
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n nLICENSES or CERTIFICATIONS
nRequired
nnNone
n nPreferred
nnnACM Certification (Accredited Case Manager) - American Case Management Association - American Case Management Association
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nnCase Management - American Board of Occupational Health Nurses (ABOHN) andCertified Case Manager (CCM)
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nnCommission for Case Manager Certification (CCMC)
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n nAdditional Employment Requirements:
nProfessional Certification within 5 years of start date. Incumbents in role as of 12/1/2022 have until 12/31/2026 to obtain
nDisclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
nCompliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
nAs a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.
nFurthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
nnnCPR - American Heart Association
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nnAct 34 Criminal Background Clearance Certificate
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nnAct 33 Child Abuse Clearance Certificate
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nnAct 73 FBI Fingerprinting Criminal Background Clearance Certificate
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n nHighmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
nCalifornia Consumer Privacy Act Employees, Contractors, and Applicants Notice (
nReq ID: J
Worksite address
monroeville, PA, 15146, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.