Company : Allegheny Health Network Job Description : At AHN, employees trust working together and place patients at the center of all they do. This 9 Hospital system, a part of Highmark Health, is transforming the future of healthcare by providing highly effective services to customers, patients and communities. AHN has commitment and dedication to being inclusive, valuing fresh perspectives, and offering the best growth and educational opportunities to employees. Forbes Hospital is a 315 bed, Level II trauma hospital located in the community of Monroeville. Our hospital offers the service lines of a city hospital, inclusive of trauma, neurosurgery, cardiothoracic surgery, interventional cardiology, obstetrics and psychiatry, while also building relationships across the organization in a community setting. GENERAL OVERVIEW: Registered nurse who is proficient in the coordination of care and manages coordination of care in accordance with recognized standards of practice for Care Management. Professional role model utilizing expertise in care management to promote a collaborative professional environment that supports excellence of care and achievement of optimal resource utilization. Also facilitates appropriate LOS, patient satisfaction and reimbursement for all patients. ESSENTIAL RESPONSIBILITIES: • Assumes role in assessment of patient physical, psychosocial, and economic needs for effective transition of care planning to a variety of levels of care. • In collaboration with the care team, facilitates the development and communication of the continuum of care transition plan to appropriate health service providers. • Documents, verifies, and validates specific data required to monitor and evaluate interventions and outcomes. Interviews and collects patient specified data and chart review related to readmission. • Knowledgeable of and complies with accreditation and regulatory requirements. Integrates performance improvement principles and customer service principles into all aspects of job responsibilities. • Obtains or ensures acquisition of appropriate pre-certification authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party guidelines. Obtains or facilitates acquisitions of urgent / emergent authorizations, continued stay authorizations and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements. • Documents, monitors, intervenes/resolves and reports clinical denials/appeals and retrospective payer audit denials. Collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor and third party payers. • Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental commercial payer guidelines. Adheres to the policies, procedures, rules, regulations and laws of the hospital and all federal and state regulatory bodies. Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care. • Assumes responsibility for AHN required continued education and own professional growth. • Performs other duties as assigned or required. QUALIFICATIONS: 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). • Professional Certification within 5 years of start date. Incumbents in role as of 12/1/2022 have until 12/31/2025 to obtain • Critical thinking and problem solving • Flexibility and adaptability to change • Strong communication and collaboration skills with ability to tailor style according to arenaflex audience (providers, peers, clinical team members, patients, families) • CPR - American Heart Association • Act 34 Criminal Background Clearance Certificate • Act 33 Child Abuse Clearance Certificate • Act 73 FBI Fingerprinting Criminal Background Clearance Certificate Preferred • Nationally recognized Case Management Certification • Transition planning and understanding of community and facility resources • Knowledge of motivational interviewing techniques • BSN LICENSES or CERTIFICATIONS Required • None Preferred • ACM Certification (Accredited Case Manager) - American Case Management Association - American Case Management Association • Case Management - American Board of Occupational Health Nurses (ABOHN) and Certified Case Manager (CCM) • Commission for Case Manager Certification (CCMC) Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. 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