REPOSTED: 20241211

Date Posted: 20241122

Location: Allegheny General Hospital

Status: Full Time

Shift:  72 hours every two weeks

36 hours per week - 3-12 hour shifts

1 weekend day shift (Saturday or Sunday) and 2 day shifts (Monday – Friday)

No overnights

Includes rotating holidays

Union: Yes

CASE MANAGEMENT:

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.

ALLEGHENY GENERAL HOSPITAL:

AGH is a Level I Shock Trauma Center

5 state of the art ICU’s

State of the art Cancer Center

550+ Beds

ALLEGHENY HEALTH NETWORK:

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.

GENERAL OVERVIEW

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.  

ESSENTIAL RESPONSIBILITIES

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.

QUALIFICATIONS

Minimum

Bachelor’s Degree in Nursing -OR- Bachelor’s Degree and Nursing Diploma -OR- 6 years of relevant experience in lieu of a degree.

3 years in a clinical nursing role

Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

Nationally recognized Case Management Certification within 5 years of start date.

Critical thinking and problem solving 

Flexibility and adaptability to change

Strong communication and collaboration skills with ability to tailor style according to target audience (providers, peers, clinical team members, patients, families)

CPR certification

Act 34 Criminal Background Clearance Certificate

Act 33 Child Abuse Clearance Certificate

Act 73 FBI Fingerprinting Criminal Background Clearance Certificate

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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