Case Manager Utilization RN-Per Diem Day

About the Role

Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and continued stays. Makes recommendations to physicians for alternate levels of care when the patient does not meet the medical necessity for inpatient hospitalization. Interacts with the 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. Transfers stable non-members to planned healthcare facilities. Responsible for complying with AB 1203, Post Stabilization notification.

Responsibilities

• Plans, develops, assesses, and evaluates care provided to members.
• Collaborates with physicians, multidisciplinary healthcare teams, 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.
• Reviews, monitors, evaluates, and coordinates patients' hospital stays to ensure timely and efficient delivery of all appropriate and essential services.
• Participates in Bed Huddles and carries out recommendations congruent with patients' needs.
• Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining authorizations/approvals 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 (e.g., TJC, DHS, HCFA, CMS, DMHC, NCQA, DOL).
• Educates healthcare team members on their roles in the discharge planning process and appropriate use of resources.
• Provides patients with education to assist with discharge and help them cope with psychological problems related to acute and chronic illness.
• Reports any unusual occurrences related to quality, risk, or patient safety as per established protocols.
• Reviews, analyzes, and identifies utilization patterns, trends, problems, or 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/apply principles, practices, techniques, and methods of utilization review/management, discharge planning, or case management.
• Working knowledge of regulatory requirements and accreditation standards (e.g., TJC, Medicare, Medi-Cal).
• Demonstrated ability in written/verbal communication, interpersonal skills, critical thinking, and problem-solving.
• Strong planning, organizing, conflict resolution, and negotiating skills.
• Computer literacy skills.

Preferred Qualifications

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

Schedule

• Per Diem (as needed).
• Shift: Day (08:30 AM – 05:00 PM).
• Workdays: Sun, Mon, Tue, Wed, Thu, Fri, Sat.

Pay

$77.69 - $95.08 per hour.