RN, Case Manager III (UR)

RN, Case Manager III (UR)

Title: RN Case Manager III

Location: Long Beach

Department: Care Coordination

Status: Full time

Shift: Day

Pay Range: $61.98/hr - $86.73/hr

At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. Memorial Care stands for excellence in Healthcare. Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.

Position Summary

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.

Essential Job Outcomes & Functions

Care Management

The case manager III independently manages a specific case load of patients as identified by the Resource Management Department and CareLines. The case manager analyzes patient information and assess each patient's functional status and decision making ability in relation to the continuum of care and discharge needs. The case manager collaborates with the health care team, patient, and family in planning and facilitating the achievement of expected outcomes for patients. Each treatment plan is evaluated for appropriate quality outcomes and utilization of resources.

Continuum of Care/Quality

The case manager III works collaboratively with the health care team to provide education, resources, and referrals as needed for each patient and their family or caretaker. The case manager facilitates coordination among health care professionals, services, and settings involved in the patient's care, with a focus on enhancing patient satisfaction. The case manager actively communicates with nursing leadership, CareLine physician directors, and Medical Directors on quality issues. As appropriate, concerns are referred to various Medical Staff Committees and CareLines through required documentation, including but not limited to the Clinical Pertinence Review Form. The case manager has the responsibility to maintain professionalism and provide ongoing education to the health care team regarding the case manager's role.

Utilization Management

The case manager works collaboratively and proactively with payors in managing patient resources. The case manager 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. The case manager utilizes the billing system to analyze charges vs. reimbursement and contract information. This information is used to structure the health care team toward effective utilization of resources. The case manager incorporates knowledge of medical necessity, CareLine protocols, and MAPs to evaluate for appropriateness of admissions, continued stay, and discharges. The case manager refers cases, as appropriate, for review to the Combined Resource Management Committee and other Medical Staff Committees as needed.

Qualifications

Experience: This position requires strong verbal and written communication skills with the ability to communicate well with people from diverse socioeconomic backgrounds. The case manager is knowledgeable of criteria for medical necessity for each level of care through the continuum of care. A knowledge of reimbursement related to MediCare, MediCal, Capitation, and Managed Care is required. Three to five years acute care or home health experience plus prior experience in Quality Improvement, Case Management, Discharge Planning or Utilization Management required.

Education: Current California RN License. BSN or Bachelors degree in health or related field preferred

Primary Location

United States-California-Long Beach

Work Locations

LBMMC-LBMMC Hospital 2801 Atlantic Avenue Long Beach Long Beach 90806

Job

Case Mgmt, Utilization Review

Organization

Long Beach Memorial Medical Center

Schedule

Full-time

Employee Status

Regular

Job Level

Staff