Case Manager II- Sharp Memorial Hospital - FT - Days

Hourly Pay Range: $69.070 – $75.080 – $96.480 (placement within the range based on years of RN experience, as defined by the collective bargaining agreement between Sharp HealthCare and Sharp Professional Nurses Network, United Nurses Associations of California/Union of Health Care Professionals, NUHHCE, AFSME, AFL-CIO).

What You Will Do

The RN CM II 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 and quality considerations with regulatory, financial, and utilization review demands to ensure patients receive care in the appropriate setting and level of care. The role balances individual clinical needs with efficient and cost-effective utilization of resources while promoting quality outcomes, requiring critical thinking, advanced problem-solving, and time management skills. The RN CM II will partner with ICM leadership to mentor and precept new hires (CMI, SW, LVN Care Coordinators, and CRCs).

Responsibilities

• Assess, develop, implement, coordinate, and monitor comprehensive care plans for patients and families in collaboration with the interdisciplinary team.
• Ensure patients receive care in the appropriate setting and level of care by balancing clinical needs with regulatory, financial, and utilization review standards.
• Mentor and precept new hires, including CMI, Social Workers, LVN Care Coordinators, and CRCs.
• Actively participate in performance planning, competency development, and individual development planning.
• 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 appropriate care, setting, and utilization standards.
• Assure efficient patient progression through hospitalization and the continuum of care for all age groups.
• Communicate positively, effectively, and professionally with others; lead, supervise, teach, and collaborate.
• Work closely with the healthcare team to achieve unit, facility, and system goals, including reducing length of stay, decreasing denials, improving care transitions, and reducing avoidable readmissions.
• In emergency departments, collaborate with the interdisciplinary team to develop preadmission status recommendations and implement integrated discharge plans for patients transitioning to lower levels of care.
• Recommend and document patient classification (status and level of care) for all admissions using established criteria.
• Maintain compliance with contractual and regulatory requirements for medical groups and the hospital.
• Interview patients/families within 24 hours of admission to assess post-hospitalization needs and document plans in the electronic medical record (EMR).
• Develop and document a "plan for the day" and "plan for the stay" with patients, families, providers, and nursing staff.
• Lead daily care coordination rounds, update plans, and facilitate service coordination.
• Initiate and document discharge plans, including early referrals and authorizations for LTAC, SNF, Rehab, homecare, DME, and infusion services.
• Prepare patients and families for discharge, document expected discharge dates, and arrange discharge logistics.
• Conduct routine patient/family conferences in collaboration with Social Workers.
• Ensure safe and effective patient handovers to the next level of care, working closely with ambulatory care managers, clinic staff, and homecare/sub-acute liaisons.
• Support the nursing Model of Care to achieve Patient and Family Centered Care goals: respect, dignity, information sharing, participation, and collaboration.
• Facilitate early discharges to improve capacity management and document avoidable days in the EMR.
• Participate in initiatives to reduce barriers to discharge.
• Collaborate with Clinical Resource Coordinators (CRCs) to ensure appropriate referrals and obtain prior authorizations for in-network and out-of-network services.
• Provide timely delivery of regulatory and mandated patient communications and correspondence.
• Oversee preparation, delivery, and documentation of non-coverage letters.
• Identify and escalate potential quality variances to management and document per guidelines.
• Interview patients readmitted within 30 days to determine discharge issues and document findings in the EMR.
• Conduct initial review at point of entry (POE) or within 24 hours of admission using evidenced-based care guidelines and document findings in the EMR.
• Identify anticipated length of stay (LOS) and communicate it to the healthcare team.
• Conduct daily concurrent reviews per protocol/policy and payer requests, using care guideline software to determine correct patient status and level of care.
• Work with attending providers to resolve status conflicts and document interventions in the EMR.
• Ensure correct documentation for 2MN benchmark and presumption, and follow Condition Code 44 requirements for Medicare status changes.
• Manage observation patient lists to ensure transitions to the next level of care.
• Communicate with third-party payers to obtain necessary authorizations for reimbursement.
• Obtain approved days/LOS from providers and communicate this to the care team.
• Refer defined cases for medical secondary review and share findings with providers.
• Advise Revenue Cycle/HIM on RAC decisions, denials, appeals, and share findings with providers.
• Review cases with readmissions within 30 days and report findings in the EMR.
• Identify opportunities for cost reduction and participate in utilization management initiatives.
• Escalate and refer cases for consultation with Physician Advisor or Medical Director as appropriate.
• Manage multiple assignments effectively, organize and prioritize workload, and work independently with minimal supervision.
• Identify and act upon quality variances and handle complex cases.
• Lead and participate in special projects and assignments as needed.
• Serve as a resource point of contact as designated by ICM leadership.

Requirements

• Bachelor's Degree in Nursing or equivalent degree.
• 2 years of recent pertinent clinical experience as defined by the CBA.
• 3 years of acute care nursing experience or case management experience.
• 3 years of case management, utilization review, or care coordination experience.
• California Registered Nurse (RN) license – required.

Preferred Qualifications

• Master's Degree.
• Certified Case Manager (CCM) – Commission for Case Manager Certification.
• Accredited Case Manager (ACM) – American Case Management Association (ACMA).

Skills

• Advanced PC, data management, and analysis skills (experience with MCG is an asset).
• Understanding of payer eligibility, reimbursement regulations, and their impact on the continuum of care.
• Knowledge of community resources to coordinate safe discharges from acute care and ED settings.
• Excellent interpersonal skills, demonstrated by the ability to work effectively with individuals and teams across disciplines.
• Strong communication and negotiation skills in both oral and written forms.
• Ability to work in a collaborative partnership model with Social Workers and other interdisciplinary team members.
• Organizational and time management skills, with the capacity to prioritize multiple tasks.
• Ability to mentor and lead a team.

Schedule

Variable shift start and end times. 8-hour shifts under an 8/80 schedule. Weekend requirements as needed. On-call not required.