Penn Presbyterian Medical Center is in need of a RN Pre Certification Case Manager.
Responsibilities for this position include but are not limited to the following:
Ensures access to superior integrated health care
Achieves clinically appropriate and financially sound resource utilization
Supports the insurance verification team, clinical staff and verify accuracy of financial and contractual requirements for optimal reimbursement for the hospital's services provided.
• Interacts with medical staff and their designees to obtain complete, accurate and timely clinical and financial information required for payer reimbursement.
• Assesses clinical information for appropriateness of settling and utilization of resources to optimize patient outcomes and cost effective.
• Provides required clinical and demographically information to payer to obtain pre-certification and assure reimbursement.
• Identifys potential quality and utilization concerns and refer to the Director when appropriate. Follow up with action as indicated.
• Maintains communication with and provide education to all involved departments included but not limited to admissions, patient financial services, clinical resource management and provider medical staff and designees.
• Assists in preparation of complete, accurate and timely reports both for utilization and quality.
• Meets on a regular basis with the Director and communicate clearly the progress and status of all assigned functions.
• Identifies and implements opportunities for work redesign/cross training within the department
• Assures compliance with Federal/State regulation applications in registration EMTALA and Advance Directives as example.
• Ensures compliance with all JCAHO regulations.
• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures
• Other duties as assigned to support the unit, department, entity, and health system organization
Please apply if you possess these qualifications:
Bachelors Degree in nursing required
Active PA RN license in good standing required
5+ years RN experience in case management, utilization review, and knowledge of third party payor processes required
We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.