Case Management Skills Checklist

Requested by:

Requested by email:

Today's Date: * +

First Name: *

Last Name: *

Mobile Phone Number: *

Email Address: *

Confirm email: *

WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Hospital	123
Occupational health	123
Insurance company	123
Health maintenance organization review department	123
HMO utilization review call center	123
Home health	123
Hospice	123
Managed care service provider	123
Long-term care	123

GENERAL SKILLS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Familiar with Milliman guidelines	123
Familiar with InterQual criteria and computer software	123
Familiar with Medicare guidelines	123
National Patient Safety Goals	123
Patient/family teaching & education	123
Awareness of HCAHPS	123

REGULATING AGENCIES:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

CMS: Centers for Medicare & Medicaid Services	123
OSHA: Occupational Safety & Health Agency	123
Department of Health	123
The Joint Commission	123
HIPAA: Health Insurance Portability & Accountability Act	123
Disability management	123
Worker’s compensation	123
Data abstraction	123
Discharge planning	123

ASSESSMENT EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Assesses resource utilization	123
Cost management	123
Diagnosis	123
Past/present treatment course & services	123
Prognosis	123
Goals	123
Treatment & provider options	123
Prior authorization reviews	123
Continued stay reviews	123

PLANNING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Collaboration with client/family & members of the healthcare team	123
Identification of immediate, short-term & ongoing needs	123
Develops appropriate and necessary case management strategies	123
Discharge planning	123

EVALUATION EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Pre-certification review	123
Concurrent utilization review	123
Retrospective utilization review	123
Benefits eligibility review	123
Drug utilization review	123

SOFTWARE PROGRAMS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

MeDecision	123
TILE	123
OASIS	123

INPATIENT BASED SKILLS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Universal precautions	123
Cardiac arrest/CPR	123
Use of rapid response teams	123

AGE-SPECIFIC COMPETENCIES EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently *

Newborn / neonate (birth-30 days)	123
Infant (31 days-1 year)	123
Toddler (ages 2-3 years)	123
Preschool (ages 4-5 years)	123
School age (ages 6-12 years)	123
Adolescent (ages 13-21 years)	123
Young adult (ages 22-39 years)	123
Adult (ages 40-64 years)	123
Older adult (ages 65-79 years)	123
Elderly (ages 80+ years)	123

Attestation

ATTESTATION: *

I certify that the information provide above accurately reflects my experience in each of the clinical areas identified within the past three years.

If you agree with the Attestation above, please electronically sign your name. *