Inpatient After Hours Case Manager Senior Nurse

Summary

The After Hours Case Manager Senior Nurse is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified patients during an acute care episode after normal business hours. The After Hours Case Manager Senior Nurse will also assist the After Hours Lead as needed to provide lead coverage, scheduling, training and special projects/assignments.

Duties and Responsibilities:

• Screens incoming calls for admission against Milliman Care Guidelines (MCG) to determine if member requires Observation admissions vs Inpatient admission to the acute care setting.
• Acts as a liaison for any member/ provider calls.
• Performs clinical review upon admission.
• Coordinates interfacility transfer of patients to tertiary facilities for higher level of care.
• Coordinates repatriation of patients from out of network facilities to their contracted/ capitated facility. 
• Identifies and resolves barriers or potential barriers to safe transition and outpatient management.
• Coordinates and assures all services for care transitions; including transfer to lower level of care, transfer to outpatient management, etc.
• Coordinates and facilitates Peer to Peer discussions when deemed necessary or requested.
• Coordinates care for patients in the Emergency Room or Urgent Care to avoid an unnecessary acute inpatient admission.
• Timely document based on regulatory and contractual guidelines established by Federal, State, Local and Health plan guidelines, along with MedPOINT Management policies and associated Participating Provider Group (PPG).
• Communicates with health plans directly on complex cases 
• Consistently exhibits behavior and communication skills that demonstrate commitment to superior customer service, including quality care and concern with every internal and external member.
• Perform other duties as assigned.
• Assists in preparing the monthly schedule for the afterhours team with the After Hours Lead
• Monitors daily workload for after-hours team with the After Hours Lead
• Supports the Lead in any needs or opportunities not listed. 
• Participates in special projects and assignments as required

Minimum Job Requirements:

• Current RN or LVN licensure; Preferred: BSN level of education.
• Registered Nurse or Licensed Vocational Nurse with clinically focused work history. 
• Prefer three-five years clinical experience within an acute health care setting with recent work history in acute care case management role or related health care experience.  
• Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review/quality assurance, use of Milliman or other clinical decision support criteria, discharge planning, and reimbursement structures (i.e. Government and non-governmental payers).
• Ability to read, analyze and comprehend complex clinical data and its application to level of care criteria and discharge options; strong, broad-based clinical knowledge and understanding of pathology/physiology of disease processes; excellent critical thinking skills; assertive personality traits to facilitate ongoing physician communication;  organize, prioritize and manage time efficiently.
• Schedule will vary but must be available for a minimum of 4 shifts per week, weekends, holidays, and other scheduled closures of MedPOINT Management.

Skills and Abilities:

• Computer literacy and familiarity with the operation of basic office equipment.
• Proficient in Excel and Word.
• Knowledge of EZ-Cap.
• Must be able to communicate effectively with a wide range of hospital personnel, physicians, patients/family members.

Salary Range:

• $90k – $95k annually