Under the general supervision of system director of care management/utilization review, acts as a patient advocate/case manager to hospital clients.  An autonomous role that coordinates, negotiates, procures services, and manages the care of complex patients to facilitate achievement of quality and cost-efficient patient outcomes.  Responsible for referral intake process of potential Swing bed patients including communication of accepted patients’ requirements to multidisciplinary team.  Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health care facility to comply with government and insurance company reimbursement policies by performing the following duties personally or thru designee. Applies review criteria to determine medical necessity for admission and continued stay. Provides clinically based care management, discharge planning, authorization management and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care.

Works collaboratively with interdisciplinary staff internal and external to the organization

Swing Bed Admission Reviews
1. Promote the mission, vision, and values of the organization.
2. Evaluate referred patient’s appropriateness for acceptance into the ARH Swing Bed Program and make acceptance decisions in coordination with the facility care teams. Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.
3. Coordinate patient transfers with care managers/social workers at referring facilities to assure compliance with payer requirements for reimbursement
4. Call out differences between IPPS and CAH
5. Adhere to referral workflow
6. Track and trend data.
7. Collaborate closely with the ARH Command Center
Other Duties
8. Compilation and submission of swing bed data as necessary for hospitals that provide swing bed services.
9. Participates in all committees and performance improvement activities as assigned.
10. May cover other region as needed.
11. Serves as a care management resource expert for employees, the Medical Staff, patients and families.
12. Provides patient, family, employee and Medical Staff education as appropriate.
13. Receives ongoing education related to State and Federal health care programs, managed care organizations, preferred provider health plans, worker compensation plans, private health plans, third party payers, and criteria for continued care at multiple levels.
14. Maintains Up to date knowledge on regulatory agency guidelines as it pertains to area of practice.
15. Maintain work standards that are in compliance with ARH’s policies and governmental regulations and various regulatory agency requirements.
16. Consistently maintains a professional commitment to institutions and department’s goals and objectives. Demonstrates flexibility to the department’s needs in relation to floor and work schedule and any other internal and external demands on the department. Continually shows commitment to the department by extending one’s self when the need arises.
17. Attends and/or completes all required safety training programs and can describe his or her responsibilities related to general safety, department/service safety, and specific job related hazards.
18. Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
19. Ability to work remotely and maintain deadlines and target.

Minimum Education
LPN, RN, Bachelors or Masters prepared social worker with a state license to practice professional nursing or social work in state of resident facility. BSN preferred.
Previous experience in the area of utilization review and case management preferred.
Working knowledge of federal, state, and regulatory requirements in quality assessment, case management, resource management, hospital systems, accreditation, and licensure strongly preferred

Minimum Work Experience
Two (2) years’ experience in a short-term acute care hospital or critical access hospital setting preferred.
Prior Case Management or health finance experience desirable.
Experiential knowledge of the post hospital placement process preferred.

Demonstrated skills in the areas of negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking. Knowledge of healthcare financing, community and organizational resources, patient care processes, and data analysis.
Knowledge of post-acute care community resources.
Excellent verbal and written communication skills required.
Demonstrates flexibility via an ability to adapt to changing priorities and regulations.
Basic computer skills required.
Familiar with insurance portals

Required Licenses/Certifications
• If LPN or RN, CPR certification to be obtained within 30 days of hire.
• Certification in the area of Case Management desired
• Valid Driver’s license

Required Skills, Knowledge, and Abilities
Basic computer skills, Chart review and good working clinical knowledge base with excellent communication skills necessary to interact with physicians and medical staff. General idea of governmental and private insurance guidelines.