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Flagler Hospital

Case Manager RN, FT varied shifts
Job#: 178777
Positions: 1
Posted: 03/01/2013
Job Type: Full Time
Location: St. Augustine, FL
Department: Case Management
Category: Clinical
Salary: Hourly
Benefits: Full Benefits
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Job Description

Job Description:                                  CASE MANAGER  RN


Department:                                         Case Management


Responsible To:                                   Director of Case Management


Education/Training:                           Registered Nurse from accredited school of nursing and licensed in the state of Florida; MSW will be considered in lieu of RN. Certification in CCM or affiliated specialty preferred.  Use of Internet preferred, including e-mail.


Experience:                                           Registered Nurse requires minimum three years experience in an acute care facility working as R.N. Experience should include working on an ICU, Medical, or Surgical Unit.  An additional year of experience in the “Utilization Review” or “Case Management” field is preferable working either in an acute care hospital, PRO setting, or insurance company. Masters Degree in Social Work will be considered in lieu of acute care facility experience.  Basic experience using PC (computer) required (typing & computer keyboard). 


Skills & Abilities:                              Ability to work with physicians in case management activities and work independently without constant supervision; must have adequate clinical experience to apply to the chart screening process; ability to provide educational sessions to the medical staff and ancillary support staff regarding PRO/third party regulations and documentation concerns.  Knowledge of ICD-9-CM coding or a coding course would be highly desirable.  Knowledge of continuous quality improvement techniques is highly desirable in order to participate in quality improvement teams. Knowledge of CMS guidelines and experience working with payor specific guidelines and contractual rules is preferred. Customer services abilities including effective listening skills; critical thinking skills decisive judgment and the ability to work with minimal supervision meeting deadlines.  Assertive and persuasive communication skills, action oriented.


Physical Requirements:                    Job is mostly sedentary, but some walking between nursing units.  Some bending and stooping to look for charts; Light amounts of the following: reaching above/below the waist; fine hand/finger movements; excellent visual acuity to read and screen charts; excellent listening and auditory skills to work over the telephone and in person with physicians and insurance companies.  Good verbal communication skills to relate to the professional staff and physicians.


Environmental Conditions:                Primarily works inside.


Occupational Exposure:                     Category III = Job involves tasks or procedures that have no exposure to blood and other potentially infectious materials during the performance of duties.






  1. Documents the review process by completing a CM/UR Worksheet on selected patient populations.  Addresses the following items on the worksheet:  Criteria for selection - Admission review - P.A. referral - Case management activities - Social service collaboration - Continued stay reviews - CSR referrals - Diagnoses/procedures/consults
  2. Is knowledgeable of how to apply Interqual SI/IS Criteria to assure necessity of admission/CSR – inclusive of adults and pediatrics. Refers cases that do not meet InterQual criteria for admission/continued stay to the Physician Advisor.  Cases referred to the P.A. are relevant, well researched and summarized effectively.
  3. Demonstrates knowledge of the regulatory requirements and policy concerning observation such as: Time limitations in observation, Physician order for observation, Physician conversion order to inpatient if they now meet inpatient criteria; what diagnostic test may be more appropriate in an outpatient setting as opposed to an inpatient setting.
  4. Collaborates daily with the direct caregivers (social workers, nurses, and physicians, ancillary depts.) to coordinate the patient’s LOS, timely utilization of resources and appropriateness of those resources. Demonstrates knowledge of criteria to trigger a social services referral from case management and uses these criteria to alert social services to a potential problem case.
  5. Knowledgeable about the telephonic review policy and provides telephonic review to the third party payers (to certify the admission and/or continued length of stay) negotiating for additional days if necessary.
  6. Tracking of “Avoidable Days” in Meditech completing the necessary user defined fields of data.
  7. Assures that all Medicaid charts have been reviewed and that the physician has certified the admission (via a certification stamp in the progress notes).
  8. Flags cases for the Risk Manager and Quality Assurance Coordinator regarding adverse events, appropriateness of procedures, and quality of care issues.
  9. Enters Medicaid charts into the KePRO computerized system to obtain appropriate authorization and approval of continued stay days. Also assures timely inputs of Medicaid retro reviews when eligibility is confirmed.
  10. Confirms on admission that a copy of the “Important Message from Medicare” is in the medical records and has been dated and signed appropriately. Is able to identify patients who may be discharged within 48 hours and will require another copy of the I.M. to be given to the patient/family. Gives a copy of the I.M. to the patient/family explaining its purpose and annotates the chart appropriately.
  11. Identifies opportunities for improvement in the hospital system processes as well as suspected problems of under or over utilization in inappropriate scheduling of services and bring to the attention of the Case Management Supervisor.  Observes rules of confidentiality specific to the Q.M Department (information obtained in files, committee discussions, data security, proper disposal of QA information, etc).
  12. Performs other job related duties as assigned by Director.


The above statements reflect the responsibilities considered essential to the job as identified and shall not be considered a detailed description of all the work requirements inherent in the job.



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