RN I, Case Manager

Description

Concurrently monitors and reviews all member utilizations for medical appropriateness, makes recommendations for alternative levels of care, identifies potential barriers or delays in service, and facilitates discharge planning activities.

Professional Duties

• Performs initial inpatient admission medical necessity reviews and ongoing concurrent utilization and quality screening reviews for all, in-network, hospitalized patients using industry recognized criteria and guidelines.
• Communicates frequently with the Hospitalist(s) and Specialty provider(s) to facilitate timely consultations, solidify the plan of care, clarify the current level of care, and/or problem-solve any potential obstacles to a safe discharge.
• Makes recommendations for alternative or lower levels of care when appropriate.
• Anticipates delays in physician decision-making and takes immediate corrective action if necessary.
• Sets up immediate intervention by the Medical Director when unable to impact physician decision-making regarding potential delays in service.
• Gives daily clinical updates to team members regarding utilizations, including verbalizing the anticipated next steps for the Hospitalist(s) or Specialty Provider(s).
• Identifies aberrant days resulting from hospital process issues, gathers documentation to support the aberrancy, and reports findings to the department Director (or Designee).
• Accomplishes discharge screening on all admissions, anticipates discharge planning needs, and ensures timely and safe discharges and/or SNF transfers for medically stable patients.
• Ensures that all applicable DME and Home Health needs are met.
• Ensures that the Case Management and/or Referral Department receives sufficient supporting documentation so that all requests for post-hospital specialty care can be processed timely, completely, and without delay.
• Makes recommendations to the Hospitalist(s) and Specialty Provider(s) regarding discharge planning and dispositions.
• Updates the Daily Hospital Log and reports significant changes in patients' condition or status, as they occur, to the appropriate department via email.
• Initiates and issues timely denial notifications to the patient or their power of attorney or next of kin, in accordance with both State and Federal regulatory guidelines.
• Identifies and submits to the Quality Improvement Committee any potential or actual quality issues for their review as well as utilization issues, such as over/under utilization, delay of service issues, etc.
• Performs other duties as assigned.

Qualifications

• Current California RN license.
• 2 years recent RN acute hospital experience, including experience with telemetry, chart review, and analysis as well as a broad knowledge of the various nursing disciplines required.
• An extensive understanding of varied diagnostic and invasive procedures and the ability to anticipate care plan changes based on findings.
• An awareness of Level of Care, Intensity of Service, and Severity of Illness criteria, Discharge screens, Skilled Nursing criteria (for SNF), and Home Health criteria.
• The ability to communicate professionally and interface assertively with Physicians.
• A detail-oriented approach and the ability to continually re-prioritize multiple tasks.

Physical Demands

• Type: Sitting - Approximately 30% of day, Standing - Approximately 25% of day, Walking - Approximately 45% of day, Lifting - 0 - 40 lbs (equipment, supplies) - approximately 15% of day, Bending - Approximately 10% of day, Kneeling - Less than 20%.
• Computer: Adequate for use with computers, telephone, and/or Blackberry - Approximately 50% of day.