Case Manager LPN

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This position provides support assistance to the Case Manager and Appeal Specialist as assigned. The Care Facilitator will perform duties that include insurance determinations, third party payer authorizations and other clinical aspects of case management to improve patient care across the continuum of the patient stay and discharge.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license  through the enhanced Nurse Licensure Compact (eNLC).

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. Two (2) years clinical experience in the acute care setting.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Utilize Interqual Criteria to assure the appropriate level of care is determined in order to receive appropriate third party payer authorizations with required time frames. Base on direction from the Case Manager, will continue to provide clinical support in communication to third party payers throughout the patient stay. Will provide preparation of the daily work for the Case Manager as appropriate. Will provide coordination of physician communication to streamline daily contact.

2. Assists in managing the continuum of care from admission through discharge. In collaboration with Social Services, will facilitate cost effective/appropriate management of patient cases or discharge planning, medication authorizaton and other home/transfer needs based on the patient's plan of care. Assist Case Manager to obtain authorization for post-acute care services including SNF, DME and Home Health Care.

3. Participate in patient care conferences, daily rounds and family conferences as directed by the Case Manager.

4. Assists Case Manager with problematic cases and patient care issues required research and fact finding.

5. Audit inpatient Case Management for appropriate documentation including admit orders, length of stay certification and documentation medical necessity.

6. Collects quality and utilization date as assigned by management personnel and Appeals Specialists.

7. Assists with preparation of materials related to teleconferences, readmission reviews, denials and appeals.

8. Maintain education and licensing requirements as determined by the Director of Case Management.

9. Additional duties as assigned.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Frequent sitting, standing, walking, reaching.

2. Ability to lift and carry up to 10 pounds.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Working closely with others.

2. Working around biohazards and infectious diseases.

3. Working with electrical hazards associated with patient care equipment.

SKILLS AND ABILITIES:

1. Knowledge of insurance and authorization processes.

2. Knowledge of patient discharge needs and local community resources.

3. Knowledge of patient’s current medical insurance coverage and limitations and the precertification requirements for Durable Medical Equipment (DME), post-acute placements, infusions, transfers etc

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Company:

WH Wheeling Hospital Inc.

Cost Center:

403 WH Care Management

Address:

1 Medical Park Drive

Wheeling

West Virginia

Equal Opportunity Employer

 

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.