RN, Case Manager III (UR)

About the Role

The Case Manager III is a licensed professional who plans, coordinates, and facilitates the ongoing care and appropriate discharge plan of a specific caseload of patients through the continuum of care. The case manager III collaborates with members of the health care team, the patient, and their family to assure effective, efficient, and appropriate care and outcomes. The incumbent is accountable for education, monitoring, utilization, and evaluation of medical outcomes.

Responsibilities

• Independently manages a specific case load of patients as identified by the Resource Management Department and CareLines.
• Analyzes patient information and assesses each patient’s functional status and decision-making ability in relation to the continuum of care and discharge needs.
• Collaborates with the health care team, patient, and family in planning and facilitating the achievement of expected outcomes for patients.
• Evaluates each treatment plan for appropriate quality outcomes and utilization of resources.
• Works collaboratively with the health care team to provide education, resources, and referrals as needed for each patient and their family or caretaker.
• Facilitates coordination among health care professionals, services, and settings involved in the patient’s care, with a focus on enhancing patient satisfaction.
• Actively communicates with nursing leadership, CareLine physician directors, and Medical Directors on quality issues.
• Refers concerns to various Medical Staff Committees and CareLines through required documentation, including the Clinical Pertinence Review Form.
• Maintains professionalism and provides ongoing education to the health care team regarding the case manager’s role.
• Works collaboratively and proactively with payors in managing patient resources.
• Assures the hospital receives appropriate reimbursement through collaboration with the health care team and provides timely clinical review, as well as retroactive review for unbilled accounts.
• Utilizes the billing system to analyze charges vs. reimbursement and contract information to structure the health care team toward effective utilization of resources.
• Incorporates knowledge of medical necessity, CareLine protocols, and MAPs to evaluate for appropriateness of admissions, continued stay, and discharges.
• Refers cases for review to the Combined Resource Management Committee and other Medical Staff Committees as needed.

Qualifications

• Current California RN License.
• BSN or Bachelor’s degree in health or related field preferred.

Skills

• Strong verbal and written communication skills with the ability to communicate well with people from diverse socioeconomic backgrounds.
• Knowledge of criteria for medical necessity for each level of care through the continuum of care.
• Knowledge of reimbursement related to Medicare, Medicaid, Capitation, and Managed Care.

Experience

• Three to five years of acute care or home health experience.
• Prior experience in Quality Improvement, Case Management, Discharge Planning, or Utilization Management.

Pay

$61.98/hr - $86.73/hr

Benefits

$20,000 signing bonus available to external hires new to MHS employment, contingent upon satisfaction of employment requirements. High-quality health insurance plan options and other benefits as detailed in the MemorialCare Benefits and Rewards program.

Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities.