LVN Case Manager Assistant

About the Role

The LVN/LPN Case Manager Assistant conducts medical necessity screening and collaborates with the interdisciplinary team to provide care coordination for patients under the direction of a Registered Nurse, in compliance with evidence-based practice and regulatory requirements. This position integrates national standards for case management scope of services, including:

• Utilization Management supporting medical necessity and denial prevention
• Transition Management promoting appropriate length of stay, readmission prevention, and patient satisfaction
• Care Coordination demonstrating throughput efficiency while ensuring care is delivered in the right sequence and at the appropriate level
• Compliance with state and federal regulatory requirements, TJC accreditation standards, and policy
• Education provided to physicians, patients, families, and caregivers

Responsibilities

• Conduct accurate medical necessity screening and submission for Physician Advisor review (30% daily)
• Coordinate care and implement transition plans based on RN Case Manager and/or Social Worker assessments
• Communicate with the interdisciplinary team during patient care conferences
• Manage concurrent disputes and communicate with patients and families regarding the plan of care
• Collaborate with physicians, office staff, and ancillary departments
• Ensure clear, complete, and concise documentation in electronic systems
• Maintain accurate patient demographic and insurance information
• Identify and document potentially avoidable days, overutilization, and underutilization

Utilization Management

• Assure patients are in the appropriate status and level of care based on medical necessity and submit for Secondary Physician review per policy
• Ensure timely communication of clinical data to payers to support admission, level of care, length of stay, and authorization for post-acute services
• Advocate for patients and the hospital with payers to secure appropriate payment for services rendered
• Complete clinical reviews and promote prudent utilization of resources (fiscal, human, environmental, equipment, and services)
• Identify and document Avoidable Days to address opportunities for improvement
• Prevent denials and disputes by communicating with payers and documenting relevant information
• Coordinate clinical care supported by evidence-based practice and regulatory requirements

Transition Management

• Make referrals for post-acute services based on RN Case Manager or Social Worker assessments (30% daily)
• Provide patients and families with choices of post-acute providers per policy
• Follow up on readmitted patients and implement strategies to address opportunities
• Ensure all elements of the transition plan are implemented and communicated to the healthcare team, patient/family, and post-acute providers
• Identify and report variances in the appropriateness of medical care and resource utilization

Care Coordination

• Follow up on patients identified by the Social Worker and/or RN Case Manager on factors affecting care progression (15% daily)
• Ensure consults, testing, and procedures are sequenced to support timely and efficient care delivery
• Communicate patient needs and ensure the healthcare team is mutually accountable for achieving the patient plan of care
• Collaborate with physicians, nurses, ancillary staff, payors, patients, and families to achieve optimal clinical and transition outcomes

Education

• Contribute to education for patients and the care team regarding effective progression of care, appropriate level of care, and safe patient transition (15% daily)
• Provide information on resources and benefits available to the patient, including the economic impact of care options
• Ensure education is provided to the patient, family, and caregiver by the healthcare team prior to discharge

Compliance

• Ensure compliance with federal, state, and local regulations, and accreditation requirements impacting case management (10% daily)
• Adhere to department structure, staffing, policies, and procedures to comply with CMS Conditions of Participation and Kaiser policies
• Operate within the LVN/LPN scope of practice as defined by state licensing regulations
• Remain current with Kaiser Utilization Management/Case Management practices

Requirements

• Minimum two (2) years of hospital, ambulatory, or post-acute experience
• High School Diploma or General Education Development (GED) required
• Valid Vocational Nurse License (California)

Skills

• Excellent organizational, verbal, and written communication skills
• Demonstrated problem-solving skills
• Computer literacy
• Must complete InterQual test and pass with a score of 85 or better within 60 days of hire and annually
• Must complete and demonstrate competency in using Kaiser Utilization Management/Case Management documentation system within 60 days of hire

Preferred Qualifications

• Hospital Case Management experience preferred

Tools and Systems Used

• Patient data systems (hospital admission, discharge, transfer)
• Healthcare staff documentation related to patient care
• Regulatory and payor requirements
• Kaiser Plan benefits
• Health Connect
• Tapestry
• McKesson Care Enhance Review Manager (CERMe)
• InterQual system
• Clinical data interface and secure faxing
• Patient Medical Record (Health Connect and Tapestry)
• Hospital-specific clinical software

Performance Metrics

• InterQual reviews
• Observation hours
• Excess Days/ALOS
• Patient Day Rate
• IQM metrics
• Number and type of avoidable days
• Resource utilization

Schedule

• Full-time, 40 hours per week
• Shift: Day (08:30 AM – 05:00 PM)
• Workdays: Sun, Mon, Tue, Wed, Thu, Fri, Sat (works every other weekend)

Pay

$50.96 - $65.94 per hour