Case Manager - Care Coordination - Full Time 8 hours Days (Union, Non-Exempt)

About the role

The purpose of the Case Manager position is to support the physician and interdisciplinary team in the provision of patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. The role integrates and coordinates utilization management, care facilitation, and discharge planning functions. The Case Manager is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources.

Responsibilities

• Facilitate pre-certification and payer authorization processes.
• Facilitate the collaborative management of patient care across the continuum.
• Intervene as necessary to remove barriers to timely and efficient care delivery and reimbursement.
• Apply process improvement methodologies in evaluating outcomes of care.
• Support and coach clinical documentation efforts and serve as a clinical resource for coders, ensuring that documentation accurately reflects severity of illness and intensity of service.
• Coordinate communication with physicians.
• Actively participate in clinical performance improvement activities.
• Apply approved InterQual criteria to monitor appropriateness of admissions and continued stays and document findings based on department standards.
• Assist in the compilation of physician profile data regarding LOS, resource utilization, denied days, cost, case mix index, patient satisfaction, and quality indicators.
• Assist in the collection and reporting of financial indicators including case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials, and appeals.
• Collaborate and communicate with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation.
• Collaborate with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
• Facilitate care for designated caseload; monitor the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.
• Facilitate on a timely basis: completion and reporting of diagnostic testing, completion of treatment plan and discharge plan, modification of plan of care as necessary to meet the ongoing needs of the patient.
• Communicate to third-party payers and other relevant information to the care team.
• Assign appropriate levels of care and complete all required documentation in Affinity GUI screens and patient records.
• Collaborate/communicate with external case managers.
• Collect delay in service data and data for specific performance and/or outcome indicators as determined by the director.
• Communicate with Financial Counselor to facilitate covered day reimbursement certification for assigned patients.
• Discuss payer criteria and issues on a case-by-case basis with clinical staff and follow up to resolve problems with payers as needed.
• Complete utilization management for assigned patients.
• Coordinate/facilitate patient care progression throughout the continuum.
• Document relevant discharge planning information in the Affinity GUI System according to department standards.
• Ensure that all elements critical to the plan of care have been communicated to the patient/family and members of the health care team and are documented as necessary to ensure continuity of care.
• Ensure/maintain plan consensus from patient/family, physician, and payer.
• Facilitate transfer to other facilities.
• Identify at-risk populations using approved screening tool and follow established reporting procedures.
• Initiate and facilitate referrals to the Home Health Liaison for home health care, hospice, and medical equipment and supplies.
• Issue Notices of Non-coverage per hospital policy.
• Manage all aspects of discharge planning for assigned patients.
• Meet directly with patient/family to assess needs and develop an individualized plan in collaboration with the physician.
• Monitor all transfer DRG’s.
• Monitor length of stay (LOS) and ancillary resource use on an ongoing basis and take actions to achieve continuous improvement in both areas.
• Perform 100% UR Review on all Medicare One-Day admissions.
• Proactively identify and resolve delays and obstacles to discharge.
• Refer appropriate cases for social work intervention based on department criteria.
• Refer cases and issues to physician advisor in compliance with department procedures and follow up as indicated.
• Seek consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge.
• Use data to drive decisions and plan/implement performance improvement strategies related for assigned patients, including fiscal, clinical, and patient satisfaction data.
• Use quality screens to identify potential issues and forward information to the PI department.
• Utilize advanced conflict resolution skills as necessary to ensure timely resolution of issues.
• Work collaboratively and maintain active communication with physicians, nursing, and other members of the multidisciplinary care team to effect timely, appropriate patient management.

Requirements

• Associate’s Degree Nursing
• Registered Nurse - RN (CA Board of Registered Nursing)
• Basic Life Support (BLS) Healthcare Provider from American Heart Association

Minimum Skills

• Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.
• Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
• Excellent interpersonal communication and negotiation skills.
• Strong organizational and time management skills, as evidenced by a capacity to prioritize multiple tasks and role components.
• Understanding of pre-acute and post-acute venues of care and post-acute community resources.
• Strong analytical, data management, and PC skills.

Preferred Experience

• 3 years Clinical experience in Utilization Review and Discharge Planning in an Acute Hospital strongly preferred.

Pay

The hourly rate range for this position is $46.00 - $76.07. When extending an offer of employment, the University of Southern California Arcadia Hospital considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, State, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.