Highmark Health
RN Case Manager Inpatient, Allegheny General
Highmark Health, Pittsburgh, Pennsylvania, United States, 15201
Allegheny Health Network
The Case Management Department at Allegheny General Hospital assists patients and their support systems in managing medical conditions effectively. Our team of talented Case Managers aims to individualize health care to meet each patient's specific needs with a patient-centric and outcome-driven focus. Allegheny General Hospital is a Level I Shock Trauma Center, has five state-of-the-art ICUs, a state-of-the-art Cancer Center, and 550+ beds. Allegheny Health Network is a 9-hospital system, a part of Highmark Health, transforming the future of healthcare by providing highly effective services to customers, patients, and communities. This job oversees, develops, and manages the end-to-end claims functions and operational inputs including the receipt of claims, operational correspondences, and corporate correspondences for multiple customer segments. Fully utilizes the support mechanisms available to complete the required delivery of high-performance, efficient, and low-cost production. Responsible for mail services, imaging, and Optical Character Recognition (OCR) including vendor relations and communicating with operational areas regarding issues related to supported technology. Manage utilization review, translation of foreign claims, coordination of benefits (COB), and processing of claims with unique processing arrangements including Federal Employee Program (FEP) and Medicare Advantage. Coordinates the clinical care with the patient, family, physician(s), and other members of the interdisciplinary team. Completes and documents admission, concurrent, and discharge reviews of all inpatients and selected outpatients. Develops and implements an effective discharge plan while incorporating input from the patient, family, physician(s), and other members of the interdisciplinary team. Identifies, analyzes, collects, and communicates data relative to quality and cost issues related to the assigned patient population. Expands industry knowledge base for professional growth and development while providing ongoing applicable education to the patient, family, physician(s), and other members of the interdisciplinary team including, but not limited to, appropriateness of care, documentation requirements, severity of illness and intensity of services criteria, insurance benefits/requirements/limits, discharge planning requirements, length of stay and resource utilization issues. Adheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodies. Minimum: Bachelor's Degree in Nursing -OR- Bachelor's Degree and Nursing Diploma -OR- 6 years of relevant experience in lieu of a degree. 3 years in a clinical nursing role. Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Nationally recognized Case Management Certification within 5 years of start date. Critical thinking and problem solving. Flexibility and adaptability to change. Strong communication and collaboration skills with ability to tailor style according to target audience (providers, peers, clinical team members, patients, families). CPR certification. Act 34 Criminal Background Clearance Certificate. Act 33 Child Abuse Clearance Certificate. Act 73 FBI Fingerprinting Criminal Background Clearance Certificate.
The Case Management Department at Allegheny General Hospital assists patients and their support systems in managing medical conditions effectively. Our team of talented Case Managers aims to individualize health care to meet each patient's specific needs with a patient-centric and outcome-driven focus. Allegheny General Hospital is a Level I Shock Trauma Center, has five state-of-the-art ICUs, a state-of-the-art Cancer Center, and 550+ beds. Allegheny Health Network is a 9-hospital system, a part of Highmark Health, transforming the future of healthcare by providing highly effective services to customers, patients, and communities. This job oversees, develops, and manages the end-to-end claims functions and operational inputs including the receipt of claims, operational correspondences, and corporate correspondences for multiple customer segments. Fully utilizes the support mechanisms available to complete the required delivery of high-performance, efficient, and low-cost production. Responsible for mail services, imaging, and Optical Character Recognition (OCR) including vendor relations and communicating with operational areas regarding issues related to supported technology. Manage utilization review, translation of foreign claims, coordination of benefits (COB), and processing of claims with unique processing arrangements including Federal Employee Program (FEP) and Medicare Advantage. Coordinates the clinical care with the patient, family, physician(s), and other members of the interdisciplinary team. Completes and documents admission, concurrent, and discharge reviews of all inpatients and selected outpatients. Develops and implements an effective discharge plan while incorporating input from the patient, family, physician(s), and other members of the interdisciplinary team. Identifies, analyzes, collects, and communicates data relative to quality and cost issues related to the assigned patient population. Expands industry knowledge base for professional growth and development while providing ongoing applicable education to the patient, family, physician(s), and other members of the interdisciplinary team including, but not limited to, appropriateness of care, documentation requirements, severity of illness and intensity of services criteria, insurance benefits/requirements/limits, discharge planning requirements, length of stay and resource utilization issues. Adheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodies. Minimum: Bachelor's Degree in Nursing -OR- Bachelor's Degree and Nursing Diploma -OR- 6 years of relevant experience in lieu of a degree. 3 years in a clinical nursing role. Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Nationally recognized Case Management Certification within 5 years of start date. Critical thinking and problem solving. Flexibility and adaptability to change. Strong communication and collaboration skills with ability to tailor style according to target audience (providers, peers, clinical team members, patients, families). CPR certification. Act 34 Criminal Background Clearance Certificate. Act 33 Child Abuse Clearance Certificate. Act 73 FBI Fingerprinting Criminal Background Clearance Certificate.