Clinical Case Manager (CASE MGR NEX)

Facilitates the integration and coordination of major aspects of utilization review and discharge planning for patient needs. This position requires a high level of clinical judgment, problem-solving skills, creativity, organizational and priority-setting abilities, with excellent communication skills.

About the Role

Critical aspects of the role involve the assessment of clinical information to determine medical necessity for the identified level of care, assessment for appropriate services needed and resources available, and facilitation of coordination between internal and external health care providers to ensure optimal continuity of appropriate and cost-effective care. The Clinical Case Manager must effectively communicate with both internal and external providers, health plans, and community resources to optimize medically necessary services.

The Clinical Case Manager demonstrates the ability to fulfill responsibilities through clinical assessment, accurate and sound judgment, application of standardized criteria, and maintaining professional communication. The goal of coordinated discharge planning and utilization is achieved by actively directing and involving members of the multi-disciplinary team, outside providers, community resources, and third-party payors.

The Clinical Case Manager accurately maintains and tracks pertinent data and statistics specific to the area of practice, such as delays in service, patients who lack medical necessity for acute hospital admission, denials for continued stays, and other factors affecting appropriate utilization of health system resources.

The purpose of the Clinical Case Manager is to support the interdisciplinary team in facilitating 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 payors. The role integrates and coordinates utilization management, care facilitation, and discharge planning functions. The Clinical Case Manager helps drive change by identifying areas where performance improvement is needed (e.g., day-to-day workflow, education, process improvements, patient satisfaction). The Clinical Case Manager is accountable for a designated patient caseload and plans effectively to meet patient needs, manage the length of stay, and create a safe discharge plan.

Responsibilities

• 30% - Utilization Review and Case Finding
• 30% - Coordination and Implementation of Discharge Plan
• 15% - Communication, Coordination, and Documentation
• 10% - Secure Authorization for Care and Reimbursement for Hospital and Physician
• 10% - Denials and Appeals Management
• 5% - Quality and Education

Facilitation of the collaborative management of patient care across the continuum, completing utilization review around level of care (LOC) and authorization concerns, and intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement.

Requirements

• Valid California Registered Nurse License without restriction
• Graduation from an accredited school of nursing
• Minimum of one (1) year recent Case Management experience in discharge planning and/or utilization review management in an acute hospital
• Licensed RN with current working knowledge of discharge planning, utilization management, performance improvement, and managed care reimbursement
• Knowledge of Medicare, Medi-Cal, and HMO legislation, third-party payor contracts, Title XXII, and The Joint Commission
• Demonstrated knowledge of how these programs/regulations affect the functions and role of the department and ability to incorporate them into departmental systems/processes
• Knowledge of professional and ethical standards related to Clinical Case Management such as the Nursing Practice Act, the Codes of Ethics from the American Nurses Association, and the Standards of Practice & Scope of Services by the American Case Management Association
• Ability to read and comprehend English text and medical terminology; knowledge of medical and nursing treatment plans, levels of care, and area resources; skill in assessing the appropriateness of medical admissions and continued stay
• Skill to perform in-depth chart analysis to provide accurate information in a concise, informative manner, identify/analyze problems or issues related to areas of responsibility, develop an appropriate plan, and consider medical needs and resources available
• Ability to organize and direct varied health care team professionals in a manner that establishes a good rapport and professional working relationship
• Ability to work efficiently and independently, maintaining a calm manner while under pressure
• Ability to organize work to accommodate special projects, deadlines, and priorities; ability to be both flexible and adaptable in order to coordinate multiple variables and respond to the needs of a multi-faceted work area
• Possess clinical skills and knowledge base to assess and refer to discharge planning, possible needs for care necessary to meet patient’s needs on discharge
• Understands the need to utilize discretion and maintain confidentiality when discussing patient matters
• Successfully applies interpersonal communication skills in areas such as conflict management

Preferred Qualifications

• Bachelor of Science in Nursing (BSN)

Pay

$75.58 - $110.71 per hour

Schedule

• 100% on-site
• Days shift
• Works overtime as defined by the collective bargaining agreements, floats to other areas, and works weekends and holidays

Benefits

• High-quality and low-cost medical plans to choose from to fit your family's needs
• UC pays for Dental and Vision insurance premiums for you and your family
• Extensive leave benefits including Pregnancy and Parental Leave, Family & Medical Leave
• Paid Holidays annually as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
• Paid Time Off/Vacation/Sick Time as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
• Continuing Education (CE) allowance and Education Reimbursement Program as stipulated in the UC Davis Health Policies or Collective Bargaining Agreement
• Access to free professional development courses and learning opportunities for personal and professional growth
• WorkLife and Wellness programs and resources
• On-site Employee Assistance Program including access to free mental health services
• Supplemental insurance offered including additional life, short/long-term disability, pet insurance, and legal coverage
• Public Service Loan Forgiveness (PSLF) Qualified Employer & Student Loan Repayment Assistance Program for qualified roles
• Retirement benefit options for eligible roles including Pension and other Retirement Saving Plans

Physical Demands

• Standing - Occasional, up to 3 hours
• Walking - Occasional, up to 3 hours
• Sitting - Frequent, 3 to 6 hours
• Lifting/Carrying 0-25 lbs - Occasional, up to 3 hours
• Pushing/Pulling 0-25 lbs - Occasional, up to 3 hours
• Bending/Stooping - Occasional, up to 3 hours
• Squatting/Kneeling - Occasional, up to 3 hours
• Twisting - Occasional, up to 3 hours
• Climbing (e.g., stairs or ladders) - Occasional, up to 3 hours
• Reaching overhead - Occasional, up to 3 hours
• Keyboard use/repetitive motion - Frequent, 3 to 6 hours

Environmental Demands

• Loud noise levels - Occasional, up to 3 hours
• Marked changes in humidity or temperature - Occasional, up to 3 hours

Mental Demands

• Sustained attention and concentration - Frequent, 3 to 6 hours
• Complex problem solving/reasoning - Frequent, 3 to 6 hours
• Ability to organize & prioritize - Frequent, 3 to 6 hours
• Communication skills - Frequent, 3 to 6 hours
• Numerical skills - Occasional, up to 3 hours
• Constant Interaction - Frequent, 3 to 6 hours
• Customer/Patient Contact - Frequent, 3 to 6 hours
• Multiple Concurrent Tasks - Frequent, 3 to 6 hours

This position is designated as a mandated reporter under CANRA and UC policy, and employment is contingent on compliance with applicable policies, procedures, and training requirements. Employment is also contingent upon clearing a criminal background check(s) and may include drug screening, medical evaluation clearance, and functional capacity assessment.