UNIQUE Demorcy

• Perform an initial evaluation of the referral appropriateness for CareCentrix services. Review for information needed to make a medical necessity determination.
• Use clinical expertise, review clinical information and clinical criteria (e.g., CMS, MCGs, Interqual) to determine if the service/device meet medical necessity for the patient.
• Interact with the Medical Director as needed to ensure proper medical necessity decisions are being made in a timely manner.
• Ensure case review and elevation to complete the determination is rendered within the contractual and regulatory turnaround time standards to meet both contractual and regulatory requirements.

• Worked as RN case manager remotely conducting discharge planning for multiple Advent Health Hospitals
• Effectively communicated with physicians regarding patient needs, performance, medications and changes.
• Completed initial assessments of patients and family to determine and address individual home care needs. ·
• Coordinated with interdisciplinary professionals to develop plans of care, administer tests and monitor patient status.
• Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
• Responded promptly and professionally to patient questions and concerns.
• coordinate the plan of care and provide comprehensive care coordination and oversight of patient's care remotely
• Collaborate with members if the inter-disciplinary healthcare team
• Leads the development and implementation of the multidisciplinary plan of care for patients
• Case manager is responsible for the assessment, planning, implementation, coordination, monitoring, and evaluation of the patient's plan of care from admission to post discharge.

• Completed psychosocial assessments of patients and family to determine appropriate discharge setting (home with home health, acute rehab, or SNF)
• Responded promptly and professionally to patient questions and concerns.
• Effectively communicated with physicians regarding patient needs, performance, medications and changes.
• Negotiated with suppliers and vendors to procure medical equipment, supplies and services.
• Perform daily chart reviews, justify admissions and continued stay using Interqual criteria
• Conduct weekly concurrent reviews and submit updated clinicals to commercial payers
• Communicated with payers to obtain authorizations for reimbursement of services
• Managed caseload of up to 20 patients
• Participate in weekly round multidisciplinary rounds to identify, plan, treat, and implement discharge requirements to reduce length of stay.
• Serve as a Medicare, Medicaid, and commercial insurance liaison to the hospital and maintain updated knowledge of rules and regulations

• Communicate effectively with physician, nurses, and other axillary staff.

• Perform initial assessment of each patient before the start of each dialysis treatment.

• Prepare dialyzer and delivery system for each patient in accordance with physician orders. Initiate hemodialysis treatment through arterial venous fistulas, arterial venous grafts, and central venous lines.

• Initiate, monitor, and conclude each hemodialysis treatment.

• Evaluate patient vital signs, and hemodynamic stability during each hemodialysis treatment. • Ensure all hemodialysis equipment is thoroughly cleaned after each use.

• Administer prescribed medications orally and intravenously.