Allegheny Health Network Careers

Job Number: CCRC
Location: Allegheny Center
Department:  Case Management
Status: Full time, 40 hours/week
Shift: M-F,  8-4:30pm with weekend rotation.This position will require travel to assigned AHN entities as needed.

Welcome to Allegheny Health Network (AHN), a proud member of Highmark Health. Working as an integrated delivery system based in western Pennsylvania, AHN includes seven hospitals, three health + wellness pavilions, and hundreds of primary and specialty care offices, with more than 1,700 physicians, 17,000 employees, and 2,000 volunteers.

AHN’s nationally recognized doctors and healthcare professionals are continuously exploring and advancing innovative treatments to provide accessible and quality care. Comparion Medical Analytics ranked many of our programs among the best in the country, according to its 2016 National Quality ratings. Also, other organizations, including Thomson Reuters and Consumer Reports, have recognized our dedication to excellence and world-class medicine.

AHN is a national leader in the healthcare industry, committed to improving health and promoting wellness in our community, one person at a time. We are dedicated to continually learning and exploring new, better, and creative ways to serve our patients, our employees and our community.

 
Job Responsibilities:

• Assumes role in assessment of patient physical, psychosocial and economic needs for effective transition of care planning to a variety of levels of care.
• In collaboration with the care team, facilitates the development and communication of the continuum of care transition plan to appropriate health service providers.
• Documents, verifies and validates specific data required to monitor and evaluate interventions and outcomes.
• Interviews and collects patient specified data and chart review related to readmission.
• Knowledgeable of and complies with accreditation and regulatory requirements. Integrates performance improvement principles and customer service principles into all aspects of job responsibilities.
• Obtains or ensures acquisition of appropriate pre-certification authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party guidelines. Obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements.
• Documents, monitors, intervenes/resolves and reports clinical denials/appeals and retrospective payer audit denials. Collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor and third party payers, etc.
• Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as a educational resource to all AHN staff regarding utilization review practice and governmental commercial payer guidelines. Adhere to the policies, procedures, rules, regulations and laws of the hospital and all federal and state regulatory bodies.
• Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
• Assumes responsibility for AHN required continued education and own professional growth. Performs other duties as assigned or required.

Job Requirements: 

• BA/BS degree and nursing diploma required.
• Current PA RN license required.
• InterQual preferred
• Nationally recognized Care Management Certification within 5 years of start date (3 years for currently employed) required.
• CPR.
• Minimum 2-3 years of recent clinical RN acute care experience required. Discharge planning and community resource knowledge preferred. Care facilitation and utilization review experience preferred.