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RN SNF Specialist - UM

Job Description

Accountable for coordinating, developing, executing, monitoring and evaluating all Case Management activities.  Case Management activities encompass: utilization review, resource management, coordination of care, and transition/discharge planning, across the episode or continuum of care.   Works in collaborative practice with the physician and other members of the health care team to meet patient-specific and age-related patient needs, linking cost resource management and quality to patient care.   Completes established competencies for the position within designated introductory period.   Other related duties as assigned.





General Functions:



• Supports the Collaborative Care Management Model as a working partner with physicians, social workers, pharmacists and other professional staff.



• Demonstrates proficiency in the application of National clinical case review criteria and appropriate levels of care across the care continuum for managing complex cases and related episodic care events.



• Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively.



• Demonstrates an understanding of funding resources, services and clinical standards and outcomes.



• Demonstrates knowledge of case management standards of practice and processes including identification and assessment, planning, interventions and evaluation.



• Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement



• Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals.



• Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address utilization/resource and progression of care issues.  Assists in developing and implement an improvement plan to address issues.



• Develop discharge plan in coordination with and act as a resource to the facility Care Manager and Discharge Planner.



• Implement discharge plan to prevent avoidable days or delays in discharge.



• Transition patient to next level of care in coordination with facility Discharge Planner.



• Re-certify appropriate post-acute care.



• Identify and refer complex risk members to case management.



• Complete documentation completely and accurately in accordance with:  (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements.



• Identify documents and refer cases to the UM Team Leader for medical review when services do not meet medical necessity criteria and/or appropriate level of care.



• Identify and refer cases to the UM Team Leader for potential quality indicators.



• Maintains objectivity in decision making, utilizing facts to support decisions.



• Supports the mission statement, policies and procedures of the organization.



• Assists in eliminating boundaries to achieve integrated, efficient and quality service



• Achieves ongoing compliance with all regulatory agencies



• Serves as a resource to employees and customers as demonstrated by visibility and knowledge of issues.



• Reviews and adheres to department policies and the Utilization Management Plan and Case Management program specific requirements. 



• Completes interdepartmental education



• Accurately applies decision support criteria



• Utilizes resources efficiently and effectively



• Maintains safe environment



• Participates in Performance Improvement activities

Job Requirements

MINIMUM EDUCATION: 



• Graduate of an accredited School of Nursing





PREFERRED EDUCATION: 



• Bachelors or Masters Degree of an accredited School of Nursing





MINIMUM EXPERIENCE: 



• 3 years utilization management experience in an acute or post-acute provider,  health plan or other care company experience. 



• Working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etc.





PREFERRED EXPERIENCE: 



• 3 years experience in Utilization Review, Discharge Planning and Medical Case Management in a hospital or post-acute care setting. 



• Strong analytical and organizational skills. 



• Working knowledge and ability to apply professional standards of practice in work environment. 



• Knowledge of specific regulatory, managed care requirements.





REQUIRED CERTIFICATIONS/LICENSURE:



• Possession of current Texas State License for Registered Nurse.





PREFERRED CERTIFICATIONS/LICENSURE: 



• BLS-Obtained through approved American Heart Association Training Center or the Military Training Network (e.g., CPR)







The above job description is not intended to be an exhaustive list of all responsibilities, duties, and skills required of the job. Management retains the right to add or to change the duties of the positions at any time with or without notice.



Job Snapshot

Location US-TX-Fort Worth
Employment Type Full-Time
Pay Type Year
Pay Rate $61,200.00 - $77,000.00 /Year
Store Type Health Care
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Company Overview

Silverback

Join a growing healthcare company with an entrepreneurial spirit. NTSP Holding Company, LLC., supports more than 900 family and specialty doctors dedicated to delivering the best care to Medicare beneficiaries in North Texas. Learn More

Contact Information

US-TX-Fort Worth
Snapshot
Silverback
Company:
US-TX-Fort Worth
Location:
Full-Time
Employment Type:
Year
Pay Type:
$61,200.00 - $77,000.00 /Year
Pay Rate:
Health Care
Store Type:

Job Description

Accountable for coordinating, developing, executing, monitoring and evaluating all Case Management activities.  Case Management activities encompass: utilization review, resource management, coordination of care, and transition/discharge planning, across the episode or continuum of care.   Works in collaborative practice with the physician and other members of the health care team to meet patient-specific and age-related patient needs, linking cost resource management and quality to patient care.   Completes established competencies for the position within designated introductory period.   Other related duties as assigned.





General Functions:



• Supports the Collaborative Care Management Model as a working partner with physicians, social workers, pharmacists and other professional staff.



• Demonstrates proficiency in the application of National clinical case review criteria and appropriate levels of care across the care continuum for managing complex cases and related episodic care events.



• Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively.



• Demonstrates an understanding of funding resources, services and clinical standards and outcomes.



• Demonstrates knowledge of case management standards of practice and processes including identification and assessment, planning, interventions and evaluation.



• Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement



• Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals.



• Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address utilization/resource and progression of care issues.  Assists in developing and implement an improvement plan to address issues.



• Develop discharge plan in coordination with and act as a resource to the facility Care Manager and Discharge Planner.



• Implement discharge plan to prevent avoidable days or delays in discharge.



• Transition patient to next level of care in coordination with facility Discharge Planner.



• Re-certify appropriate post-acute care.



• Identify and refer complex risk members to case management.



• Complete documentation completely and accurately in accordance with:  (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements.



• Identify documents and refer cases to the UM Team Leader for medical review when services do not meet medical necessity criteria and/or appropriate level of care.



• Identify and refer cases to the UM Team Leader for potential quality indicators.



• Maintains objectivity in decision making, utilizing facts to support decisions.



• Supports the mission statement, policies and procedures of the organization.



• Assists in eliminating boundaries to achieve integrated, efficient and quality service



• Achieves ongoing compliance with all regulatory agencies



• Serves as a resource to employees and customers as demonstrated by visibility and knowledge of issues.



• Reviews and adheres to department policies and the Utilization Management Plan and Case Management program specific requirements. 



• Completes interdepartmental education



• Accurately applies decision support criteria



• Utilizes resources efficiently and effectively



• Maintains safe environment



• Participates in Performance Improvement activities

Job Requirements

MINIMUM EDUCATION: 



• Graduate of an accredited School of Nursing





PREFERRED EDUCATION: 



• Bachelors or Masters Degree of an accredited School of Nursing





MINIMUM EXPERIENCE: 



• 3 years utilization management experience in an acute or post-acute provider,  health plan or other care company experience. 



• Working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etc.





PREFERRED EXPERIENCE: 



• 3 years experience in Utilization Review, Discharge Planning and Medical Case Management in a hospital or post-acute care setting. 



• Strong analytical and organizational skills. 



• Working knowledge and ability to apply professional standards of practice in work environment. 



• Knowledge of specific regulatory, managed care requirements.





REQUIRED CERTIFICATIONS/LICENSURE:



• Possession of current Texas State License for Registered Nurse.





PREFERRED CERTIFICATIONS/LICENSURE: 



• BLS-Obtained through approved American Heart Association Training Center or the Military Training Network (e.g., CPR)







The above job description is not intended to be an exhaustive list of all responsibilities, duties, and skills required of the job. Management retains the right to add or to change the duties of the positions at any time with or without notice.



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RN SNF Specialist - UM Apply now