Case Management Utilization RN, 40/hr Day

Works collaboratively with a physician to coordinate and screen for the appropriateness of admissions and continued stays. Makes recommendations for alternate levels of care when the patient does not meet medical necessity for inpatient hospitalization. Interacts with family, patient, and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate, and manages patients in the most cost-effective way without compromising quality.

Responsibilities

• Plans, develops, assesses, and evaluates care provided to members.
• Collaborates with physicians, multidisciplinary healthcare team, and patient/family in developing, implementing, and documenting individualized plans of care to ensure continuity, quality, and appropriate resource use.
• Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
• Assesses high-risk patients in need of post-hospital care planning and develops/coordinates discharge plans to meet identified needs.
• Communicates the plan to physicians, patients, family/caregivers, staff, and community agencies.
• Reviews, monitors, evaluates, and coordinates the patient’s hospital stay to ensure timely and efficient delivery of appropriate services.
• Participates in Bed Huddles and carries out recommendations congruent with patient needs.
• Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining authorizations for outside services.
• Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in various settings (outpatient, emergency room, inpatient, and non-KFH facilities).
• Acts as a liaison between inpatient facilities and referral facilities/agencies, providing case management to referred patients.
• Refers patients to community resources to meet post-hospital needs.
• Coordinates transfer of patients to appropriate facilities and maintains required documentation.
• Adheres to internal and external regulatory and accreditation requirements (TJC, DHS, HCFA, CMS, DMHC, NCQA, DOL).
• Educates healthcare team members on their roles in the discharge planning process and appropriate resource use.
• Provides patient education to assist with discharge and help cope with psychological problems related to acute and chronic illness.
• Reports unusual occurrences related to quality, risk, or patient safety per established protocols.
• Reviews, analyzes, and identifies utilization patterns, trends, and inappropriate resource use; participates in data collection and analysis for special studies or routine monitoring.
• Coordinates, participates in, or facilitates care planning rounds and patient-family conferences as needed.
• Participates in committees, teams, or other work projects/duties as assigned.

Requirements

• Two (2) years combined RN experience in an acute care setting or case management.
• Completion of an accredited RN training program that allows graduates to take the RN license exam.
• Registered Nurse License (California).
• Basic Life Support certification.
• Demonstrated ability to utilize principles, practices, techniques, and methods of utilization review/management, discharge planning, or case management.
• Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc.).
• Strong written and verbal communication, interpersonal, critical thinking, and problem-solving skills.
• Planning, organizing, conflict resolution, and negotiating skills.
• Computer literacy skills.

Preferred Qualifications

• Bachelor’s degree in nursing or a healthcare-related field.

Schedule

• Full-time (40 hours per week).
• Day shift: 08:30 AM – 05:00 PM.
• Required to work every other weekend.
• Onsite at Orange Co Anaheim Medical Center.

Pay

$64.74 - $79.23 per hour. Actual base pay determined at offer based on labor market data, internal alignment, and candidate’s experience, education, certifications, skills, and geographic location.