REPOSTED: 20241206, REPOSTED: 20241122, Date Posted: 20240228, Location: Allegheny General Hospital, Department: Case Management, Emergency Department/CDU, Status: Full Time, Shift: 80 hours every two weeks, Steady Nights, 40 hours per week, rotating weekends and holidays, Union: Yes. 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. AGH is a Level I Shock Trauma Center with 5 state of the art ICU’s, State of the art Cancer Center, and 550+ Beds. 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. This job oversees, develops, and manages the end-to-end claims functions and operational inputs including but not limited to 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 (IDT) 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 qualifications include Bachelor’s Degree in Nursing or equivalent experience, 3 years in a clinical nursing role, current PA RN licensure or multi-state licensure through eNLC, CPR certification, nationally recognized Case Management Certification within 5 years of start date, critical thinking and problem solving skills, flexibility and adaptability, and strong communication and collaboration skills. Compliance with HIPAA and company policies is required. Highmark Health prohibits discrimination based on protected veteran status, disability, or any protected category under law.
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