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Case Manager - Case Management/Denials and Appeals * Days - 40hrs/wk in Wyoming, MI at Metro Health

Date Posted: 3/6/2018

Job Snapshot

Job Description

General Summary:

The Case Manager works in partnership and in a leadership role with physicians and the interdisciplinary team to coordinate the care and service of selected patients across the continuum. This role’s underlying objective is to enhance the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates, coordinates and promotes efficient and effective utilization management, care facilitation and discharge planning functions.

Essential Functions and Responsibilities:

Utilization Management:

  1. Applies approved clinical appropriateness criteria for assigned patients to monitor appropriateness of admissions and continued stays, and documents findings accordingly based on policy. Evaluates for appropriate setting and level of care.
  2. Refers inappropriate observation or anticipated admission cases to the Physician Advisor.
  3. Explores strategies to reduce length of stay and resource consumption while maintaining optimal patient outcomes. Takes action to achieve continuous improvement in both areas.
  4. Obtains certification for unscheduled/emergency admissions, as directed by health plan. Negotiates with payors to get coverage for out-of-plan services.
  5. Collaborates with providers and ancillary departments to arrange the most cost-effective treatment plan.
  6. Reviews medical record for issues related to quality, risk management and appropriate utilization of services.
  7. Identifies potential denials or “No Bills” and develops a plan of action to address the issue with the Supervisor of Case Management.
  8. Functions as a resource for the principles of the managed care process for physicians and other disciplines and promotes case management through role modeling and education of the healthcare delivery team as related to the appropriate disposition for the patient.

Discharge Planning:

  1. Assists with social work to coordinate/facilitate patient care progression throughout the continuum.
  2. Coordinates discharge plan with patient, family, physicians and inpatient/outpatient staff to assure an individualized, timely and effective transition to the next level of care.  Continues to monitor and assess for discharge planning needs as appropriate.
  3. Collaborates and communicates with all members of the multidisciplinary team in all phases of discharge planning process; including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation.
  4. Monitors and evaluates effectiveness of the discharge planning process through outcome analysis across the continuum as appropriate.
  5. Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge. Addresses/resolves system problems impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge.
  6. Facilitates referrals and transfers to other facilities and resource needs as appropriate.
  7. Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary in the medical record to assure continuity of care.
  8. Participates in daily multidisciplinary rounds.

Clinical Performance Improvement:

  1. Assists in the collection and reporting of resource and financial indicators including case mix index, LOS, avoidable days, readmission rates, denials and appeals.
  2. Collects delay and other data for specific performance and /or outcome indicators as determined by the Director of Care Management.
  3. Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction data.
  4. Collaborates with medical staff, nursing staff and other members of the organization to eliminate barriers to efficient delivery of care in the appropriate setting.
  5. Supports and assists in facilitation of appropriate clinical documentation efforts.


  1. Other duties as assigned.
  2. Predictable and reliable attendance.

Job Requirements

Highest Education Level Preferred:Bachelors Required Degrees And Majors:
  • Bachelors in Nursing
Optional Degrees And Majors:
  • Bachelors in Nursing (Preferred)
  • Masters in Nursing (Preferred)
Required Licenses And Certificates:
  • RN Registered Nurse
Optional Licenses And Certificates:
  • OTHER LIC Other License (Preferred)
Shift:Day On Call:No Weekends:No