Per Diem RN - Case Manager - Sharp Memorial Hospital - PD - Days

What You Will Do

The RN CM 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.

The position creates a balance between individual clinical needs with the efficient and cost effective utilization of resources while promoting quality outcomes.

Required Qualifications

• 3 Years Recent acute care nursing experience or case management experience.
• California Registered Nurse (RN) - CA Board of Registered Nursing - REQUIRED
• Bachelor's Degree in Nursing - PREFERRED

Essential Functions

• Professional development: Actively participates in the performance planning, competency and individual development planning process. Maintains current knowledge of case management, utilization management, and discharge planning, as specified by Sharp, federal, state, and private insurance guidelines.
• Core principles: Makes 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.
• Care coordination and discharge planning: Within 24 hours of admission, interviews each patient/family for anticipated needs post hospitalization. Develops and documents a plan for the day and plan for the stay with patient, family, providers, and nursing staff. Leads the daily care coordination (multidisciplinary) rounds, updates the plan, and facilitates necessary coordination of services. Prepares patient/family for discharge. Documents expected discharge date per protocol and arranges discharge pick up appointment with family or significant other. Ensures effective and safe patient handovers to next level of care; works 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. Facilitates increased volume of cases discharged early in the day to improve capacity management. Collects and documents avoidable days information in appropriate case management software, e.g., Allscripts Care Management. Participates in venues to reduce barriers to discharge. Collaborates with Clinical Resource Coordinators (CRCs/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. Oversees preparation, delivery and documentation of non-coverage letters. Identifies and escalates potential quality variances to management and documents per guidelines. Interviews all patients with an admission within 30 days to determine what went wrong in the discharge. Documents as appropriate in Cerner and Allscripts Care Management and provides information to the department head as indicated.
• Utilization review and utilization management: Conducts initial review at POE or within 24 hours of admission utilizing appropriate care guidelines software. Documents findings in CM software, e.g., Allscripts Care Management. Identifies anticipated LOS and documents in Allscripts Care Management, communicates to healthcare team. Conducts daily concurrent reviews per protocol/policy and payer request. Utilizes appropriate care guideline software to identify the correct patient status and level of care. Works with attending provider to assure correct status, if status and order does not match; works with provider to resolve conflict and document interventions in Allscripts Care Management. Assures correct documentation is present for 2MN benchmark and presumption. Assures Medicare Inpatient to observation status changes follow Condition Code 44 requirements. Actively works observation patient list assuring transitions to next level of Care. Communicates as indicated with third party payers to obtain necessary authorization for reimbursement of services. Obtains approved days/LOS from provider and communicates this to the care team. Refer defined cases for medical secondary review and share findings with providers. Provides advice to Revenue Cycle/HIM regarding RAC decision to appeal, denials, input into appeals, share findings with providers. Reviews all cases with readmission within 30 days; reports findings in Care Management software such as Allscripts. Identifies opportunities for cost reduction and participates in appropriate utilization management venues. Escalates and refers cases for consultation with Physician Advisor or Medical Director as appropriate. Oversees preparation, delivery and documentation of non-coverage letters.

Knowledge, Skills, And Abilities

• PC, data management and analysis skills required, (experience with InterQual, and or MCG and Allscripts Care Management 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 evidenced by capacity to prioritize multiple tasks.

Pay

$69.070 - $75.080 - $96.480

The stated pay scale reflects the range 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. Placement within the range is based on years of RN experience.