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

In collaboration with the interdisciplinary team, the Case Manager provides care coordination services evaluating options and services required to meet an individual’s health care needs to promote cost-effective, quality outcomes. Responsibilities Documenting and Planning Document patients’ case management plans and ongoing activities. Identify patients’ insurance coverage or other sources of payment for services. Identify and address patient risk factors and/or obstacles to care. Identify patient needs, current services, and available resources, then connect the patient to services and resources to meet established goals. Communicate the care preferences of patients, serve as their advocate, and verify that interventions meet the patient’s needs and treatment goals. Screen patients and/or populations for healthcare needs. Develop a patient-focused case management plan. Educate the patient/family/caregiver about the case management process and evaluate their understanding of the process. Inpatient Duties Concurrent review of all patients to validate that the appropriate patient status is assigned upon admission and prior to discharge. InterQual or MCG reviews 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 Clinical Care Coordination Effectively manage a case load, supporting up to 100 commercial outpatients. Utilize the online work list to manage daily assigned caseload, as assigned by the Lead Ambulatory Care Manager. Assess physical and biopsychosocial needs of the patient through clinical assessment and utilizing data from multiple sources. Analyze and interpret data in collaboration with patient, family, physician, health care team to develop a plan of care. Ensure that a specific plan of care is in place for all patients and complete all tasks on time. Coordinate care such as schedule patients’ appointments, arrange transportation, etc. Actively participate in interdisciplinary meetings and team huddles. Answer phone calls from providers, facilities, or patients related to status and processing of requests received from ambulatory care management nurse. Assess ongoing discharge planning needs and document changes to the plan in the computer system. Collaborate with social workers to ensure patient psychosocial needs are met. Collaborate with care team members, including pharmacy, behavioral health, field team, office staff, and facility staff. Complete Medicare One Day Stay forms and Medicare disposition forms timely. Consultant Demonstrate 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. Serve as a consultant to the health care team to identify financial issues that may affect care. Participate in the education of health care team members on current healthcare issues impacting best practices industry standards. Educate physicians and health care team on program referral criteria. Leadership Represent the department in a positive and professional manner. Assist with orientation of new staff. Delegate and assist with supervision of Ambulatory Care Management Coordinators. Make appropriate referrals to supervisor or Medical Director, communicating accurate clinical information. Participate in guideline (MCG and/or InterQual) competency testing as requested by department director or Medical Director. Outcomes Management Participate in core measure or HEDIS measure processes in identification of appropriate patients. Participate in hospital and med group quality improvement processes and helps identify opportunities to improve care. Adhere to program policies and procedures. Patient Advocacy Respect patient/family values, beliefs, and preferences. Respond promptly to patient/family requests. Support patient/family with end-of-life issues, making appropriate referrals into palliative care or hospice care. Include patient/family in care decisions and developing plans of care. Patient Education Assist health care team with identification of patient/family educational needs for discharge. Inform patient/family of discharge plans. Work with Transitions of Care process, to deliver post-acute services addressing educational needs to ensure a safe discharge plan. Work with patient/family to learn self-management methods for ongoing monitoring and treatment of chronic conditions. Resource Management Propose alternative treatment options to ensure a cost effective and efficient plan of care. Identify and create 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. Maintain awareness of current managed care contract requirements. Coordinate management of all inpatient activities/processes, including 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 inpatient services. Perform and document (InterQual or MCG) guideline-based assessments: upon admission, upon a change in level of care, every 2 days, and upon discharge. Participate in InterQual and/or MCG competency testing. Perform telephonic, and if appropriate, on-site initial/concurrent review on identified inpatient members. Direct pertinent clinical information/questions to contracted inpatient hospitalists, PCPs, Medical Director and/or Director of Health Services on cases of complexity. Complete clinical reviews and plans of care timely and communicate to appropriate care team members. Prioritize clinical reviews, caseloads, census loads, and assignments. Other duties as requested or assigned. Qualifications Required Qualifications Associate’s Degree in 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 in 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) – card required within 30 days of hire and maintained by renewal. The hourly rate range for this position is $53.00 – $87.45. USC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability, or any other characteristic protected by law or USC policy. USC observes affirmative action obligations consistent with state and federal law. #J-18808-Ljbffr University of Southern California