RN Case Manager - Value Based Service Organization - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

About the role

The Case Manager provides care coordination services, evaluates options and services required to meet an individual's health care needs, and promotes cost-effective, quality outcomes. They serve as a consultant to members of the health care team in the management of specific patient populations.

Responsibilities

• Documenting patients' case management plans and on-going activities
• Identifying patients' insurance coverage or other sources of payment for services
• Identifying and addressing patient risk factors and/or obstacles to care
• Identifying patient needs, current services, and available resources, then connecting the patient to services and resources to meet established goals
• Communicating the care preferences of patients, serving as their advocate, and verifying that interventions meet the patient's needs and treatment goals
• Screens patients and/or population for healthcare needs
• Developing a patient-focused case management plan
• Educating the patient/family/caregiver about the case management process and evaluating their understanding of the process
• Concurrent review of all patients to validate that the appropriate patient status is assigned upon admission and prior to discharge
• InterQual or MCG reviews are completed within 24 hours of admission
• Observation patients are effectively care managed on a daily basis
• Facilitate throughput and timely discharges throughout inpatient level of care

Essential Duties

• Able to effectively manage a case load, supporting up to 100 commercial outpatients
• Utilizes the online work list to manage daily assigned caseload, as assigned by the Lead Ambulatory Care Manager
• Assesses physical and biopsychosocial needs of the patient through clinical assessment and utilizing data from multiple sources, as supported by the ambulatory care coordinator
• Analyzes and interprets data in collaboration with patient, family, physician, health care team to develop a plan of care, and as supported by the ambulatory care coordinator
• Ensures that a specific plan of care is in place for all patients. Timely completion of all tasks, from the plan of care
• Provide coordination of care such as schedule patients’ appointments, arrange transportation, etc. as outlined in policy and procedures
• Actively participates in interdisciplinary meetings and team huddles
• Answer phone calls from providers, facilities, or patients, related to the status and processing of requests received from ambulatory care management nurse
• Assesses ongoing discharge planning needs and documents is computer system as changes to the plan occur
• Demonstrates collaborative working relationship with social workers to ensure patient psychosocial needs are met
• Demonstrates collaborative working relationship with care team members, including pharmacy, behavioral health, field team, office staff, and facility staff
• Completes Medicare One Day Stay forms timely
• Completes disposition form for medicare patients timely

Consultant

• Demonstrates sound clinical knowledge base regarding CM standards, UM standards, clinical standards of care, NCQA requirements, CMS guidelines, Milliman guidelines, InterQual guidelines, Medicaid/Medicare contracts and benefit systems, and employee health plans
• Serves as a consultant to the health care team to identify financial issues that may affect care
• Participates in the education of health care team members on current healthcare issues impacting best practices industry standards
• Educates physicians and health care team on program referral criteria

Leadership

• Represents the department in a positive and professional manner
• Assists with orientation of new staff
• Delegates and assists with supervision of Ambulatory Care Management Coordinators
• Makes appropriate referrals to supervisor or Medical Director, communicating accurate clinical information
• Participates in guideline (MCG and/or InterQual) competency testing as requested by department director or Medical Director

Outcomes Management

• Participates in core measure or HEDIS measure processes in identification of appropriate patients
• Participates in hospital and med group quality improvement processes and helps identifies opportunities to improve care
• Adheres to program policies and procedures

Customer Service

• Respects patient/family values, beliefs, and preferences
• Responds promptly to patient/family requests
• Supports patient/family with end of life issues, making appropriate referrals into palliative care or hospice care
• Includes patient/family in care decisions and developing plans of care
• Assist health care team with identification of patient/family educational needs for discharge
• Informs patient/family of discharge plans
• Works with Transitions of Care process, to deliver post acute services to address educational needs to ensure a safe discharge plan
• Works with patient/family to learn Self-Management methods for on-going monitoring and treatment of chronic conditions

Resource Management

• Proposes alternative treatment options to ensure a cost effective and efficient plan of care
• Identifies and creates solutions to remove barriers that may impede optimal patient care
• Complete case management care plans, including tasks and interventions, that effectively prevent ER Visits, Hospital admissions, or Re-admissions
• Maintains awareness of current managed care contract requirements
• Coordinate the management of all in-patient activities/processes, including but not limited to concurrent and retrospective reviews, authorization of appropriate lengths of stay, authorization of appropriate discharge services and equipment, and documentation of all authorized and/or denied in-patient services
• Performs and documents (InterQual &/or MCG) guideline-based assessments: A) upon admission, B) upon a change in level of care, C) every 2 days, and D) upon discharge
• Collaborate with Medical Director, PCP/Primary Care Team and Director of Health Services on cases of complexity with treatment plans or out of network services
• Completes clinical reviews and plans of care timely and communicates to appropriate care team members
• Able to prioritize clinical reviews, caseloads, census loads, and assignments
• Other duties as requested or assigned

Qualifications

• Associate’s Degree Nursing
• 5 years Clinical experience
• 2 years Ambulatory case management or utilization review experience within the last three years
• Ability to work independently with minimal supervision, exercising judgment and initiative
• Ability to manage multiple tasks with effective prioritization
• Process oriented
• Good computer skills

Preferred Qualifications

• Bachelor’s Degree Nursing
• Knowledge of CM standards, UM standards, clinical standards of care, NCQA requirements, CMS guidelines, Milliman guidelines, InterQual guidelines, and Medicaid/Medicare contracts and benefit systems
• 2 years Experience in an HMO/IPA/Managed care setting

Required Licenses/Certifications

• Registered Nurse - RN (CA DCA)
• Basic Life Support (BLS) Healthcare Provider from American Heart Association
• Fire Life Safety Training (LA City)