Clinical Case Manager Job Description

Clinical Case Manager Job Description

192 votes for Clinical Case Manager
Clinical case manager provides teaching, consultation, guidance, and advice for physician intent for admission and application of Interqual or Milliman Criteria to determine appropriateness of admissions.

Clinical Case Manager Duties & Responsibilities

To write an effective clinical case manager job description, begin by listing detailed duties, responsibilities and expectations. We have included clinical case manager job description templates that you can modify and use.

Sample responsibilities for this position include:

Excellent knowledge of the denial/appeal process, Governmental and Third party payers audit processes
Assist students with mental health services coordination and needs, including, but not limited to, referral to community resources and facilitate access to care
Demonstrates knowledge of community resources
Provides recommendations for community resources to patients and families including alert systems, community partners, and prescription assistance
Identify clinical indications for admission
Track hospital events and course in order to justify patient admission and continued stay for payer reimbursement
Communicate with third party payers regarding patient clinical progress
Assess and communicate potential reasons for payer denials and attempts to resolve the denial with the team at the time of identification
Participate in activities of identifying high risk vulnerabilities to the organization
Use critical thought processes and decision making in monitoring the continuum of care

Clinical Case Manager Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Clinical Case Manager

List any licenses or certifications required by the position: CCM, ACM, BLS, CPR, CPI, P/SL, COS, CT, RAC, CEU

Education for Clinical Case Manager

Typically a job would require a certain level of education.

Employers hiring for the clinical case manager job most commonly would prefer for their future employee to have a relevant degree such as Master's and Bachelor's Degree in Education, Social Work, Nursing, Health, Human Services, Psychology, School of Social Work, Social Service, Management, Medical

Skills for Clinical Case Manager

Desired skills for clinical case manager include:

Computer applications
Milliman Care Guidelines
Principles of Managed Care
Denial/appeal process
Excel and Microsoft Word
Medical necessity monitoring tools- InterQual
Governmental and Third party payers audit processes
Community resources
Large university teaching hospitals

Desired experience for clinical case manager includes:

Assumes responsibility for ongoing concurrent assessment of patient care needs through patient rounds, and communication with direct nursing care givers, physicians, patient and family members, and other members of the health care team
Utilizes principles of growth and development and the aging process, and makes appropriate decisions for patients based upon their age, (neonate, child, adult, geriatrics ) as necessary
Establishes a therapeutic working relationship with patients, physician, and family and patient care team
Leadership in care management rounds
Review cases for appropriateness of admission, continued stay and appropriate discharge screening for discharge appropriateness in accordance with hospital and/or medical staff best practice protocols, case management screening tool, adhering to the all hospital’s policies and procedures, and case management department’s scope of practice and services
Assimilates information obtained from the emergency department visit, information system, ancillary/diagnostic tests, registration, bed management, clinics, admitting physician office, and other facilities to accurately assess patient clinical needs and treatment

Clinical Case Manager Examples


Clinical Case Manager Job Description

Job Description Example
Our growing company is looking for a clinical case manager. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for clinical case manager
  • Based on admission presenting signs and symptoms or diagnosis
  • Obtains patient admission to hospital authorization from payer, as assigned, and/or per hospital system/case management policies and processes
  • Minimum 2 years’ experience in hospital utilization review, care coordination, discharge planning or has experience in a community-based care management role with commercial payers, inpatient rehab hospital care management, or home care services care manager role
  • Utilizes Care Manager
  • The case manager is responsible for communicating with the physician when the patient does not meet criteria for requested services
  • Physician variances and delays are recorded and trends are reported to the Manager of Case Management and/or Director of Case Management
  • Collaborates with the interdisciplinary team to maintain appropriate levels of care in order to expedite the movement of the patients to alternate levels of care throughout the continuum
  • Evaluates current health status including insurance coverage status and potential payor issues
  • Communicates effectively utilizing all available internal and external methods, , wireless, fax, voice mail, email
  • Interviews patients and families to determine the current DC needs of the patient
Qualifications for clinical case manager
  • Reviews patient treatment plans to proactively identify opportunities to facilitate efficient movement through the healthcare continuum, coordinating all aspects of hospitalization and discharge planning and ensuring effective and efficient utilization of resources
  • Coordinates with Social Services when patients are referred to HHC agencies, hospice agencies, Adult Care Living Facilities and Skilled Nursing Facilities
  • Communicates with patients and their families regarding discharge appeal rights (Important Message for Medicare or Medicare replacement inpatients)
  • Is a graduate of an approved school of Nursing
  • A minimum of five years of nursing experience within the acute care setting with one year of charge or supervisory position preferred
  • Ability to direct, instruct and advise in the approved methods, procedures and practices employed in effective discharge planning

Clinical Case Manager Job Description

Job Description Example
Our company is growing rapidly and is looking to fill the role of clinical case manager. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical case manager
  • Follow up to ensure that clients are appropriately assessed, successfully referred, and compliant with treatment recommendations
  • Initiate and maintain ongoing liaison relationships with community health providers, services, hospitals, and other resources
  • Provide day time and on-call after hours crisis services
  • Provide emergency/crisis care in the form of triage services
  • Collaborate and consult with key stakeholders on- and off-campus to develop and maintain comprehensive and multidisciplinary mental health care for students
  • Consult with faculty, staff, students, family members and student guardians
  • Requires some evening and weekend work
  • Provide outreach, consultation and emergency/crisis services
  • Conduct routine triage appointments for access to services
  • Understands, supports and complies with the mission, policies and procedures of the SHCC and University
Qualifications for clinical case manager
  • Demonstrates effective organizational, oral and written communications, problem solving, program development, computer, strong leadership and team building skills
  • Must be proficient to expert in use of software conducive to developing and presenting program deliverables including, but not limited to, the Microsoft Office Suite
  • Experience in performance improvement, preferred
  • Assist Vice President of Student Affairs as needed
  • Bachelor’s degree in a healthcare-related or life sciences field OR a high school diploma and 5 years of equivalent experience in a health related field
  • The Registered Nurse-Clinical Case Manager, in collaboration with physicians, and other interdisciplinary team members provide patient care coordination, care planning, facilitation and coordination of discharge needs for hospitalized patients in the acute care setting, and or during the emergency room discharge process

Clinical Case Manager Job Description

Job Description Example
Our company is searching for experienced candidates for the position of clinical case manager. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical case manager
  • Performs initial and ongoing care management assessments to determine, based on patients presenting signs and symptoms, attending physician’s documented assessment, daily care planning, care coordination, and facilitation of continuum of care discharge needs as appropriate while in the inpatient setting
  • Conducts utilization review-case reviews on all admissions, regardless of payer or admission status type, within one working day of admission from all points of entry, and utilization review continued stay reassessments as scheduled throughout the course of the patient’s hospital stay
  • Anticipates and/or identifies patient educational needs, discharge planning issues and effectively collaborates with the team leader, social worker, and attending physician to expedite early discharge planning
  • Registered Nurse Case Manager hired into the case management department with limited experience in a hospital- based clinical case management program may participate in an orientation, education and departmental preceptorship program
  • Identifies patients with significant deviations from the plan of care, and works collaboratively with physicians, staff, support services and patient/family toward resolution
  • Collaborates with the interdisciplinary care team on daily basis, and discusses information regarding significant changes in patient status, episode of care, and discharge plans
  • Assumes responsibility for clinical (LOC) discharge planning to ensure safe transitions to the community or post-acute care in collaboration with social work for social discharge planning needs
  • Initiates a discharge checklist
  • Confirms follow-up appointment with primary care physician and/or outpatient clinics, as assigned
  • Minimum 2 years’ experience in hospital utilization review, care coordination, discharge planning or has experience in a community-based care management role with commercial payers, inpatient rehab hospital care management, or home care services care manager role preferred
Qualifications for clinical case manager
  • 1-3+ years of Case Management and Discharge Planning experience preferred, but not required
  • 5 years clinical practice experience, as a Registered Nurse , hospital setting, alternative care setting such as home health or previous Case Management experience required
  • Requires ability to document electronically using keyboard and computer documentation screens - free form text
  • Managed Care, Med/Surg, and/or Behavioral Health experience preferred
  • BSN, licensure as a professional and 3 years behavioral health clinical practice
  • Licensed behavioral health clinician/nurse who has Certification as a Case Manager in addition to geriatric clinical experience is preferred

Clinical Case Manager Job Description

Job Description Example
Our growing company is looking to fill the role of clinical case manager. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for clinical case manager
  • Assesses clinical information to participate in the development of patient care plans on a continuum through communication with direct nursing caregivers, physicians, and other members of the health care team
  • Assesses and make decisions which include age-specific assessment of the patients, and/or patient population served (neonate, child, adult, geriatric)
  • Assures the progress pathway/patient plan of care is initiated within the Emergency Department and in the Outpatient areas as needed identifying individualized patient’s health risk factors, goals/expected outcomes post emergency room(ED) discharge
  • Communicates case objectives to individuals involved in providing care to optimize compliance with the plan of care and intervenes when variances occur in the patient's individualized plan of care
  • Identifies and directly addresses issues that effects patient care outcomes, collaborates with appropriate providers to prevent recurrence of issues
  • Establishes networks and referral sources to maximize utilization of available community/regional resources
  • Provides nursing and discharge planning expertise in collaboration with other health care professionals, to include the emergency room physician(s), Hospitalists, primary care physician and specialists, if required
  • Acts as an advocate for an individual’s health care needs post ED discharge
  • Establishes a trusting relationship with patients and families by active listening
  • Provides a referral base or community-based healthcare provider partnership, and advocacy to gain access to services and resources for patients
Qualifications for clinical case manager
  • Minimum of three (3) years in acute medical/surgical/ED/ or critical care nursing area required
  • Current knowledge of pathophysiology, clinical treatments, signs/symptoms which may indicate a pregnant member has an acute or declining change of health, changing health risks
  • Minimum of 3 years of experience in utilization management
  • Identify patient’s barriers to self-care and the additional services needed at discharge, eg., home health, DME, caregiver support
  • Implements skills and intervention processes to include coaching, coordination, education of patient/family, health team members
  • Understands the physical and psychological characteristics of the disease process in the service specialty and utilizes this knowledge to coordinate resources to meet the needs of the patient’s wellness and functional level

Clinical Case Manager Job Description

Job Description Example
Our innovative and growing company is hiring for a clinical case manager. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical case manager
  • Works with patients and families to assist them in understanding and participating in the development of transition plan for community-based care
  • Utilizes teach back techniques to reinforce discharge instructions by the emergency department physician or nurse
  • Minimum of 3-5 years as a Registered Nurse in an acute care hospital, required
  • As the Clinical Manager you are responsible for process improvement, quality assurance, and adherence to appropriate medical policy, care management best practices, relevant clinical standards, and member contract
  • The Clinical Manager hires, trains, coaches, counsels, and evaluates performance of direct reports
  • Use population-based disease management approaches and application of clinical protocols which are integral to the program
  • Serve as a core member of the patient centered medical home teams led by the physician/provider
  • Work towards the departmental goals to assure a systematic approach to the coordination of health services for patients along the care continuum in order to improve the patient experience, contain health expenditures and improve quality
  • Assist providers in effectively identifying needs and coordinating access to appropriate care and services in an effort to improve or maintain the patient's functional status and independence
  • Oversees and directs day-to-day operations, and through subordinate supervisory personnel, ensures effective management and delivery of quality nursing care on assigned unites for all shifts
Qualifications for clinical case manager
  • Prefer three-five years clinical experience within an acute health care setting with recent work history in acute care case management role or related health care experience
  • Ability to read, analyze and comprehend complex clinical and financial data and its application to level of care criteria and discharge options
  • Must have Licensure
  • LMHC, or LICSW preferred
  • Case Managers are required to be educated in current principles, procedures and knowledge domains of case management based on nationally recognized standards of case management and must be a licensed behavioral health clinician or RN
  • Fiscal skills to monitor and control costs and revenue

Related Job Descriptions

Resume Builder

Create a Resume in Minutes with Professional Resume Templates