DEFINITION/PRIMARY FUNCTIONS

The Case Manager is responsible for managing the healthcare needs, facilitation and achievement of quality and cost outcomes of all patients within Berkshire Medical Center, across the continuum. The case manager, utilizing a multidisciplinary team approach, negotiates, procures, coordinates and monitors services and resources needed by patients. The case manager is responsible for reviewing the patient at admission, and in some instances prior to admission, and concurrently throughout the hospital stay for the appropriate level of care and utilization of resources. The case manager will perform transition care planning activities to secure appropriate post hospital care arrangements and will monitor the patient during the course of their hospitalization. The case manager participates with the performance improvement initiatives undertaken by Berkshire Health Systems

POSITION QUALIFICATIONS (Minimum qualifications are required unless stated otherwise.)

Experience:

Three years clinical experience in acute care in areas such as internal medicine, surgery, orthopedics, mother/child, cardiology, oncology, psychiatry

Three years clinical experience in Rehab Setting, Home Health and Long-Term Care would be considered.

Ability to perform a comprehensive admission and discharge risk assessment related to quality, financial, payer benefit allowances and limitations, risk management and patient satisfaction. Experience specializing in utilization management (levels of care knowledge and demonstrable competence with evidence based criteria tools), discharge planning to entities throughout a continuum of care, previous care management or third party insurance review preferred

Current knowledge of CMS (levels of care determinations), appeal rights & DPH regulations required

Current knowledge of Kepro QIO (appeals) required

Knowledge of regulatory and accreditation organizations such as Joint Commission, DPH and HealthGrades preferred

Education and Training:

Masters Social Work

License, Certification & Registration:

LCSW-Licensed Clinical Social Worker required

LICSW preferred

Other Requirements:

Organizational skills. Proven ability to analyze and present data. Computer literacy. Ability to plan, implements, and evaluate change.

Data management skills preferred

Proven excellent interpersonal and communication skills

Ability to maintain confidentiality

Proven collaboration and negotiation skills with providers, patients, families, insurance organizations and government agencies

Proven ability to work independently

Proven excellent organizational skills

Demonstrated ability to establish and maintain relationships with physicians

Knowledge of local community resources required

Knowledge of Medicare, Medicaid, third party commercial payers and reimbursement required

Computer experience required with proven ability to manage multiple open applications

Skills in data comprehension, research, analysis, interpretation and judgement necessary to prepare a comprehensive summary report for files, management, legal and/or regulatory agencies upon request