Regional Claims Manager jobs in Galveston, TX

JOB SUMMARY

A professional who coordinates with the interdisciplinary team, patient/family on complex aspects of the patients’ care, and serves as a focal communication point for patients and staff. Works with the attending physician, specialists and bedside nurses, to help coordinate the patient’s transition to life after the hospital. Collaborates with nursing homes, home health agencies, acute rehabilitation centers, long term acute care hospitals, medical-equipment providers and insurance companies to seamlessly facilitate a patient’s move to the next level of care. The Case Manager is a clinician who is accountable for assessing the complex discharge plan, effective and efficient utilization of resources, meeting established professional and regulatory standards and providing diagnosis and medication specific education to accomplish agreeable patient/family outcomes. The Care Manager also analyzes the condition of each patient carefully in relation to medical necessity and appropriate utilization of resources.

MINIMUM QUALIFICATIONS

• Graduate of a Texas approved school of nursing; Bachelors of Science in Nursing preferred.
• Current State of Texas licensure to practice professional nursing
• Two years acute care experience required.
• Must maintain current knowledge and skill level and show evidence of continuing education in the form of seminars, webinars, and/or workshops.
• Must demonstrate excellent clinical knowledge and be able to perform assessments and evaluate services, and display excellent interpersonal and leadership competence in order to interact effectively with the patient, patient’s family, community service providers, physicians and other healthcare team members including payers, etc.
• Organizational skills with a well-developed style of diplomacy, assertiveness and a tolerance for ambiguity.
• Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
• Must demonstrate the ability to prioritize workload and manage time efficiently.
• Knowledge of clinical pathways, protocols, order sets and their application.
• Ability to use word processing programs. Ability to utilize spreadsheets and databases preferred.
• Self-motivated and innovative. Must be able to work with minimal supervision.
• Flexible with working knowledge of all areas of medicine.

ESSENTIAL FUNCTIONS

• Identifies needs of individuals as well as aggregate patient populations and assists with action to address these needs.
• Demonstrates service excellence and patient and family centered care by showing respect, honesty, fairness and a positive attitude toward all customers.
• Maintains confidentiality.
• Demonstrates dependability
• Is accountable, takes initiative and ownership of issues.
• Displays a professional demeanor. Represents hospital in a positive way. Has a compassionate working relationship with patients and families.
• Assumes personal responsibility for 2-way communication. Communicates and listens effectively with patients, families, coworkers, other departments, physicians/providers and community.
• Supports coworkers, initiatives; pitches in; does own part and helps others
• Works to continuously improve work environment/processes
• Represents willingness/enthusiasm to create, embrace and facilitate change.
• Develops working relationships critical to the organization including patients, families, coworkers other departments, physicians/providers and community.
• Encourages other by providing recognition and support.
• Improves employee and organization’s performance by removing roadblocks and empowering staff to take ownership and to be self-directed.
• Concurrent review of patient’s clinical information for medical necessity and appropriate utilization of hospital resources.