Job Summary

The Case Manager serves as a key liaison among healthcare providers, patients, families, and the multidisciplinary care team to ensure patient care is coordinated, comprehensive, and aligned with established quality, efficiency, and cost-effective standards. They monitor clinical progress, address barriers to care, and ensure that services provided support individualized goals and timely recovery throughout the care continuum. The Case Manager also facilitates patient education and discharge planning, ensuring a safe, smooth transition to the next level of care. Utilizing clinical criteria and best practices, they contribute to improved outcomes, resource optimization, and overallpatient satisfaction andorganizational performance.

Responsibilities

Care Coordination

• Collaborates with physicians, nurses, social workers, and other healthcare professional to ensure patients receive timely, appropriate, and efficient care.

• Helps develop, implement, and monitor individualized care plans based on patient’s medical needs and goals.

• Tracks patient’s progress, adjusts care plans as needed, and make sure services are delivered efficiently without unnecessary delays or duplication.

Utilization Review & Management

• Reviews patient records to ensure care is medically necessary and meets regulatory and insurance guidelines.

• Utilizes InterQual to assess level of care and communicates with insurance companies for pre-certifications or continued stay authorizations

• Monitors length of stay (LOS) and coordinates with payers to obtain authorization for continued services.

Discharge Planning

• Begins discharge planning at admissionto ensure a smooth and safe transition from hospital to home or another level of careoptimizing safe patient recovery.

• Assesses for patient’s post-discharge needs- home health care, equipment, medications, transportation, or placement in a rehabilitation or skilled nursing facility.

Patient & Family Education

• Educates patients and families about diagnosis, medications, treatment plans, discharge instructions, follow-up care, and available community resources.

• Educates patients about Advanced Directives,assists with documentation of healthcare preferences, and ensures directives are appropriately recorded.

• Educates patientson CMS-required form (CMS-R-193), delivers to patient and/or their representative, explains their rights/ responsibilities, how to request an appeal, and documents receipt of form prior to discharge.

Appeals & Denials Management

• Handles insurance denials and submits appeals with appropriate documentation and/or coordinates provider peer-to-peer review to support continued care or payment.

Documentation & Compliance

• Maintains detailed and timely documentation of all case management activities- interactions, interventions, assessments, and discharge plans, ensuring compliance with hospital policies and regulatory standards.

Quality Improvement & Advocacy

• Identifies barriers to care, advocates for patient needs, and contributes to initiatives that improve care quality and efficiency.

• Advocate for patient’s rights, ensure culturally competent.

Other Duties

• Participates in hospital committees, promoting collaborative interdepartmental relationships to support organizational goals.

• Monitoring quality indicators, proactively identifies and reports deviations or deficiencies to ensure compliance and improvement.

• Builds collaborative partnerships with community resources and external healthcare agencies to support care coordination.

• Completes mandatory training, participates in staff meetings, and pursues ongoing professional development and competency assessment to maintain clinical excellence.

• Performs other duties as required.

Knowledge, Skills & Abilities

• Requires flexibility in managing frequent interruptions and shifting priorities

• Regular interaction with patients, families, and multidisciplinary teams

• Possible exposure to bodily fluids or unpleasant clinical elements

• Frequent use of computers and phones for documentation and communications

• Occasional prolonged periods of walking, standing, and navigating the facility

• Involves lifting/carrying materials up to 10 lbs.; occasional lifting up to 25 lbs.

• A minimum of 2years’ clinical experience in a hospital is preferred.

Education

• Post High School Diploma or Certificate Program (Required)

Credentials

• Licensed Practical Nurse
• Basic Life Support (Required)

Work Schedule: Varies

Status: Full Time Regular 1.0

Location: Stonewall Jackson Memorial Hospital

Location of Job: WV:Weston:Stonewall Jackson Memorial Hospital

Talent Acquisition Specialist: Amanda G. Jeffreys 2n33w@9xchoz.com