Case Manager, Utilization RN - PRN

Case Manager, Utilization RN - PRN

Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and continued stays either telephonically or on-site. Makes recommendations to the physicians for bed day management and alternate levels of care when the patient does not meet the medical necessity for inpatient hospitalization, skilled nursing or post-acute benefits. Interacts with the family, patient and other disciplines (including but not limited to MDs, RNs, Social Workers) to coordinate a safe and acceptable discharge plan, as needed. Functions as an indirect caregiver, patient advocate and manages patients in the most cost-effective way without compromising quality.

Essential Responsibilities:

• Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with peers, multidisciplinary teams and multitask and in a fast pace environment.
• Plans, develops, assesses and evaluates care provided to members. Reviews, monitors, evaluates and authorizes the medical necessity of inpatient, skilled, or sub-acute admissions demonstrating knowledge and experience in the application of clinical criteria to determine medical necessity for inpatient hospitalization, skilled nursing or post-acute venues of care. Performs all utilization review activities according to Resource Stewardship department policies and procedures.
• Participates in clinical review round activities preparing case presentation and documentation. Notifies facilities and others of review decisions timely after applying approved criteria and/or established guidelines, including adverse determinations, as recommended by the Medical Director. Identifies high-risk/high utilizers of services to monitor their intensity and level of services and reports potential high dollar cases appropriately per policies and procedures. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs in collaboration with discharge planners and care managers, as necessary. Documents all necessary information timely into medical management systems or pursuant to appropriate policies and procedures ensuring complete and accurate data. Participates in the Bed Huddles and/or telephonic concurrent review calls and carries out recommendations congruent with the patients needs.
• Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies. Refers patients to community resources to meet post hospital needs through discharge planning and care management. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL.
• Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.
• The union and the company are currently investigating the qualifications for this position under the bargaining unit. If it is determined that the qualifications are different than as described, appropriate action will be taken.

Basic Qualifications:

• Minimum two (2) years clinical experience as an RN in an acute care setting required.

Education

• Graduate of board approved RN program and completed a minimum of 750 clock hours of faculty planned clinical experience and guided learning activities which required direct supervision by faculty, associate nursing instructional personnel (ANIP) or preceptor who is physically present or immediately accessible.
• High School Diploma or General Education Development (GED) required.

License, Certification, Registration

• Registered Nurse License (Colorado)
• Basic Life Support

Additional Requirements:

• Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of Utilization review/management, discharge planning or case management.
• Working knowledge or application of Milliman or Interqual clinical criteria.
• Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc).
• Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem-solving skills.
• Demonstrated ability in planning, organizing, conflict resolution and negotiating skills.
• Computer literacy skills required.

Preferred Qualifications:

• N/A