RN Case Manager

Miami Jewish Health is one of the largest providers of healthcare and living options for aging adults in the Southeast. Our main campus is located on 20+ acres just north of mid-town Miami, and is home to our support departments like Finance, Accounting, Human Resources, Marketing and more. Join us now to do purposeful work with our diverse and respectful team.

Job Title: RN Case Manager

Job Summary

The RN Case Manager is a registered nurse tasked with the evaluation and implementation of health care plans for individual patients. This position is focused on supporting effective and efficient medical care while managing the costs of treatment. The RN Case Manager also acts as a liaison between patients, their families, doctors, and health care providers.

Essential Job Functions

• Performs comprehensive review of pre-admission clinical documentation, upon request, to develop baseline understanding of clinical and functional goals to determine admission eligibility and validate level of care determinations
• Conducts prior authorization review on all services that require nurse review and negotiates appropriate level of care with the payor case manager or UM department; Utilizes "Managed Care Contract Matrix" to identify exclusions and carve-outs that may require separate prior authorization or care level increases
• Completes screening tool/documentation focused on the identification of clinical anchors (diagnoses, treatments, therapy) that support the definition of skilled care in the SNF setting per Medicare Benefits Policy Manual, Chapter 8, Section 30
• Fluent in MJH Managed Care contracts and incorporates clinical language into the development of bullet point list of specific clinical comorbid conditions that contribute to the complexity of each patient's individualized care plan once admitted to the facility. This patient-specific skilled coverage list will be presented to the HMO/Managed Care insurance company as evidence for requested level of care authorization prior to admission and to maintain authorization throughout MJH admission
• Populates facility CRM with authorization details and ICD-10-CM medical diagnoses for claim accuracy and compliance to ensure payment timeliness and reduce ADR negative outcomes
• Serves as liaison between physician, care team members, payor, and the discharge planner by coordinating, monitoring, and communicating patient's progress and cost evaluation and assisting with coordination to the next level of care
• Assists with the development and oversight of a Managed Care Utilization Review Committee including all interdisciplinary team members that aligns discussions with clinical and functional treatment plans with authorization maintenance and discharge planning
• Completes a comprehensive preadmission screening (PASRR), as required by KEPRO and ACHA regulations, on nursing facility admissions

Job Requirements

Education:

• Associates Degree or bachelor's degree in Nursing

Experience:

• Prior experience working in a setting that serves the elderly population is preferred

Licenses/Certifications:

• Current RN license by the Florida State Board of Nursing
• Current BLS Certification required

Abilities Required

• Ability to work with physical and emotionally frail, elderly and/or disabled persons
• Spanish language proficiency may be required

Functional Demands

Environment Work Conditions:

• Normal working condition with adequate lighting and ventilation

Infectious Material Exposure:

• N/A

Organizational Expectations

• Ensures that resident's/patient's rights are adhered to
• Demonstrates professionalism and accountability
• Demonstrates a caring attitude consistent with Miami Jewish EmpathicareSM toward MJH residents, patients, family members, employees, and other facility guests
• Demonstrates excellent communication skills
• Ensures confidentiality and security of patients' medical information
• Identifies and utilizes appropriate channels of communication
• Able to speak, read and write English
• Able to think and act calmly to meet unusual occurrences of the job
• Adheres to the organization's Mission, Vision and Values
• Participates in departmental activities, meetings and in-services and follows established guidelines
• Maintains a safe working environment

The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.

We believe in the power of empathy, the value of relationships and the importance of a life well-lived. Come see why Miami Jewish Health is unlike anywhere you've ever worked before. We offer competitive compensation, medical/dental/vision coverage and a 403(b)-retirement savings plan for eligible full and part-time positions, free on-campus parking, an onsite fitness center and more.

Miami Jewish Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.