Case Management Skills Checklist Personal InformationName(Required) First Middle Last Last 4 Digits of Social Security NumberEmail(Required) Date MM slash DD slash YYYY Proficiency Scale1 – No Experience 2 – Need Training 3 – Able to perform with supervision 4 – Able to perform independentlySettingsAcute Care 1 2 3 4 Skilled/LTAC 1 2 3 4 MDS Coordinator 1 2 3 4 Home Health 1 2 3 4 Telephonic 1 2 3 4 Workers Compensation 1 2 3 4 Insurance 1 2 3 4 Managed Care 1 2 3 4 Acute Rehab 1 2 3 4 CM/UR SoftwareInterqual 1 2 3 4 Milliman 1 2 3 4 MIDAS 1 2 3 4 Allscripts UR 1 2 3 4 Word Processing Software 1 2 3 4 Other Software RegulatoryCMS/Medicare 1 2 3 4 HEDIS Measures 1 2 3 4 Blood Flow Rate 1 2 3 4 Core Measures 1 2 3 4 Medicaid/Medical 1 2 3 4 DRG 1 2 3 4 ICD 9 Coding 1 2 3 4 ICD 10 Coding 1 2 3 4 CPT 1 2 3 4 ProcessessBenefits Eligibility 1 2 3 4 Pre-Certification Review 1 2 3 4 Review for Admission Criteria 1 2 3 4 Identify Appropriate Level of Care 1 2 3 4 Review Status During Stay 1 2 3 4 Discharge Planning 1 2 3 4 Physician Advisor 1 2 3 4 Clinical Documentation Improvement 1 2 3 4 Needs Assessment/Order DME 1 2 3 4 Needs Assessment/Home Health 1 2 3 4 Needs Assessment/Hospice 1 2 3 4 Needs Assessment/Skilled 1 2 3 4 Third Party Authorization Process 1 2 3 4 Concurrent Review 1 2 3 4 Retrospective Review 1 2 3 4 Professional Knowledge & SkillsNational Patient Safety Goals 1 2 3 4 Age Specific/Population Based Care 1 2 3 4 Age Specific CompetenciesInfant (Birth - 1 year) 1 2 3 4 Preschooler (ages 2-5 years) 1 2 3 4 Childhood (ages 6-12 years) 1 2 3 4 Adolescents (ages 13-21 years) 1 2 3 4 Young Adults (ages 22-39 years) 1 2 3 4 Adults (ages 40-64 years) 1 2 3 4 Older Adults (ages 65-79 years) 1 2 3 4 Elderly (ages 80+ years) 1 2 3 4 EMREpic 1 2 3 4 Cerner 1 2 3 4 Eclipsys 1 2 3 4 McKesson 1 2 3 4 Meditech 1 2 3 4 Allscripts 1 2 3 4 Other: Specify EMR Conversion Yes No CertificationsBLS Yes BLS Expiration Date Month Day Year Certified Case Manager (CCM) Yes Certified Case Manager (CCM) Expiration Date Month Day Year Accredited Case Manager (ACM) Yes Accredited Case Manager (ACM) Expiration Date Month Day Year Certified Disability Management Specialist (CDMS) Yes Certified Disability Management Specialist (CDMS) Expiration Date Month Day Year Certified Clinical Documentation Specialist (CCDS) Yes Certified Clinical Documentation Specialist (CCDS) Expiration Date Month Day Year ACLS Yes ACLS Expiration Date Month Day Year Other: Please note any ICD 10 training Other Expiration Date Month Day Year Other: Specify Other Expiration Date Month Day Year AuthorizationsSignature(Required)The information I have given is true and accurate to the best of my knowledge. I hereby authorize Hired by Matrix, Inc. to release this Case Management Skills Checklist to Client facilities of Hired by Matrix, Inc. in consideration of my assignment to work at those facilities.
