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Department: Case Mgmt/Social Services
Status: Full Time
Shift: Varies
Hours Per Shift: 12 Hour Shift
Job Details:
  • Job Objective:  The position is responsible for evaluating the medical necessity for admission and appropriateness of patient care unit placement for all scheduled admissions, direct admits, transfers, and outpatient conversions and provides consultation to physicians prior to patient placement.

    Licensure/Certification Required:  CA RN License

    Experience Required:  Minimum 3 Years Recent Acute Care Hospital Case Management

    Skills, Knowledge and Abilities Required:

    Strong clinical and critical thinking skills and ability to establish and carry out complex plans of care for key diagnoses

    Knowledge of regulations, standards and legislation (local, state and federal) related to the continuum of care and patient transition

    Knowledge of the various health care delivery systems and payer prior approval requirements.

    Knowledge and ability to use established criteria for medical necessity, including Interqual guidelines

    Knowledge of notices of non-coverage/denial letters to patients including Medicare/CMRI, federal and state and guidelines.

    Self motivated, self starter, and able to organize efforts around helping clients have a positive experience.

    Strong communication skills, particularly verbal and written. Ability to establish and maintain collaborative and effective working relationships. Able to assert needs to patients, families, physicians and other members of the interdisciplinary team while maintaining established rapport and relationships

    Ability to exercises a high degree of initiative, judgment, and discretion.



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