Case Manager I - Sharp Grossmont Hospital - FT - Days

The Role

The RN CM I assesses, develops, implements, coordinates and monitors a comprehensive plan of care for each patient/family in collaboration with the physician, social worker and all members of the interdisciplinary team in the inpatient and emergency department patient care areas.

This position requires the ability to combine clinical/quality considerations with regulatory/financial/utilization review demands to assure patients are receiving care in the appropriate setting and level of care.

This position requires critical thinking and advanced problem-solving and time management skills.

Qualifications

• 2 Years Recent acute care nursing experience, case management experience or equivalent experience in the healthcare setting.
• California Registered Nurse (RN) - CA Board of Registered Nursing - REQUIRED
• Bachelor's Degree in Nursing or equivalent degree - PREFERRED
• Certified Case Manager (CCM) - Commission for Case Manager Certification - PREFERRED
• Accredited Case Manager (ACM) - American Case Management Association (ACMA) - PREFERRED

Essential Functions

• Actively participates in the performance-planning, competency and individual development planning process.
• Maintain current knowledge of case management, utilization management, and discharge planning, as specified by Sharp, federal, state, and private insurance guidelines.
• Make timely referrals to ensure that the patient is receiving the appropriate care, in the appropriate setting and using the appropriate utilization standards as set by community and professional standard as adopted by the medical staff.
• Affirmative actions to assure patients are receiving care in the appropriate setting and level of care.
• Relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following and/or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, collaborate and accept direction.
• Professional development.

Core Principles

• Actively participates in the performance-planning, competency and individual development planning process.
• Maintain current knowledge of case management, utilization management, and discharge planning, as specified by Sharp, federal, state, and private insurance guidelines.
• Ensure patient choice is obtained and documented in accordance with all state and federal regulatory requirements.
• Develop and document a plan for the day and plan for the stay with patient, family, providers, and nursing staff.
• Document and initiate discharge plan including early referrals and authorization for LTAC, SNF, Rehab, homecare, DME and infusion services.
• Prepare patient/family for discharge. Document expected discharge date per protocol and arrange discharge pick up appointment with family or significant other.
• Follow standards for routine patient/family conference.
• Work closely with ambulatory care manager (ACM) at the system level, in clinics, with SCMG and other complex care Case Managers as appropriate, and homecare and sub-acute liaisons.
• Support the nursing Model of Care by working closely with nursing managers and staff to achieve Patient and Family Centered Care goals: respect and dignity, information sharing, participation and collaboration.
• Facilitate increased volume of cases discharged early in the day to improve capacity management.
• Collect and document avoidable day's information in appropriate care management software.
• Participate in venues to reduce barriers to discharge.
• Collaborates with Clinical Resource Coordinators (CRC's/clinical assistants) to assure appropriate referrals for care and services are directed to appropriate network providers, and obtains prior authorization for in network and out of network services as appropriate.
• Provides timely delivery of regulatory and mandated patient communications and correspondence.
• Oversight preparation, delivery and documentation of non-coverage letters.
• Identifies and escalates potential quality variances to management and document per guidelines.
• Interviews all patients with an admission within 30 days to determine what went wrong in the discharge. He/she documents as appropriate in the electronic medical record and provides information to the department head as indicated.
• Utilization review and utilization management.

Knowledge, Skills, And Abilities

• PC, data management and analysis skills required (experience with MCG an asset).
• Excellent interpersonal skills, as demonstrated by the ability to work effectively with individuals and or teams, and across disciplines.
• Excellent communication and negotiation skills as demonstrated in oral and written forms.
• Ability to work in a collaborative partnership model with Social Workers and other members of the interdisciplinary team, both internal and external.
• Organizational and time management skills, as evidence by capacity to prioritize multiple tasks.