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

Case Manager, RN – Value Based Service Org – 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. Serves as a consultant to members of the health care team in the management of specific patient populations. The role integrates the functions of complex case management, utilization management, quality management, discharge planning assessment, and coordination of post-hospital care services, including transfers to an alternative level of care. As more complex medical treatment options emerge the Case Manager will look to eliminate gaps in the care provided, as well as needlessly duplicated treatment, all while controlling the cost of quality patient care. The Case Manager will leverage their clinical and social work experience to bring an understanding of the clinical process of assessment, planning, implementation, and evaluation to the process of case management. Essential Duties Clinical Care Coordination Able to effectively manage a case load, supporting up to 100 commercial outpatients. Utilizes the online work list to manage daily assigned caseload, as assigned by the Lead Ambulatory Care Manager. Assesses physical and biopsychosocial needs of the patient through clinical assessment and utilizing data from multiple sources, as supported by the ambulatory care coordinator. Analyzes and interprets data in collaboration with patient, family, physician, health care team to develop a plan of care. Ensures that a specific plan of care is in place for all patients and completes all tasks in a timely manner. Provides coordination of care such as scheduling appointments, arranging transportation, etc., as outlined in policy and procedures. Actively participates in interdisciplinary meetings and team huddles. Answers phone calls from providers, facilities, or patients regarding status and processing of requests received from ambulatory care management nurse. Assesses ongoing discharge planning needs and documents changes to the plan in the computer system. Demonstrates collaborative working relationship with social workers to ensure patient psychosocial needs are met. Demonstrates collaborative working relationship with the care team members, including pharmacy, behavioral health, field team, office staff, and facility staff. Completes Medicare One Day Stay forms timely and completes disposition forms for Medicare patients timely. Consultant Demonstrates 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. Serves as a consultant to the health care team to identify financial issues that may affect care. Participates in the education of health care team members on current healthcare issues impacting best practices in industry standards. Educates physicians and health care team on program referral criteria. Leadership Represents the department in a positive and professional manner. Assists with orientation of new staff. Delegates and assists with supervision of Ambulatory Care Management Coordinators. Communicates accurate clinical information to supervisor or Medical Director and makes appropriate referrals. Participates in guideline competency testing as requested by department director or Medical Director. Outcomes Management Participates in core measure or HEDIS measure processes in identification of appropriate patients. Participates in hospital and medical group quality improvement processes and helps identify opportunities to improve care. Adheres to program policies and procedures. Patient Advocacy Respects patient/family values, beliefs, and preferences. Responds promptly to patient/family requests. Supports patient/family with end of life issues, making appropriate referrals into palliative care or hospice care. Includes patient/family in care decisions and developing plans of care. Patient Education Assists healthcare team with identification of patient/family educational needs for discharge. Informs patient/family of discharge plans. Works with Transitions of Care process to deliver post acute services to address educational needs and ensure a safe discharge plan. Works with patient/family to learn self‑management methods for ongoing monitoring and treatment of chronic conditions. Resource Management Proposes alternative treatment options to ensure a cost‑effective and efficient plan of care. Identifies and creates solutions to remove barriers that may impede optimal patient care. Completes case management care plans, including tasks and interventions, that effectively prevent ER visits, hospital admissions, or readmissions. Maintains awareness of current managed care contract requirements. Coordinates the management of all inpatient activities/processes, including concurrent and retrospective reviews, authorization of appropriate lengths of stay, authorization of discharge services and equipment, and documentation of authorized and/or denied inpatient services. Performs and documents guideline-based assessments (InterQual / MCG) upon admission, upon a change in level of care, every 2 days, and upon discharge. Participates in InterQual and/or MCG competency testing. Performs telephonic and, if appropriate, on‑site initial/concurrent review on identified inpatient members. Directs pertinent clinical information/questions to contracted inpatient hospitalists, PCPs, Medical Directors and/or Director of Health Services. Collaborates with Medical Director, PCP/Primary Care Team and Director of Health Services on cases of complexity with treatment plans or out of network services. Completes clinical reviews and plans of care timely and communicates to appropriate care team members. Prioritizes clinical reviews, caseloads, census loads, and assignments. Other duties as requested or assigned. Required Qualifications Associate’s Degree Nursing (RN). 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 Nursing. 2 years experience in an HMO/IPA/Managed care setting. 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. Required Licenses/Certifications Registered Nurse - RN (CA DCA). Basic Life Support (BLS) Healthcare Provider from American Heart Association. Fire Life Safety Training (LA City); if no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date (Required within LA City only). The hourly rate range for this position is $53.00 – $87.45. Equal Opportunity and Discrimination Statement 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. USC will consider for employment all qualified applicants with criminal records in a manner consistent with applicable laws and regulations, including the Los Angeles County Fair Chance Ordinance and the Fair Chance Initiative for Hiring Ordinance. We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone at View phone number on click.appcast.io, or by email at View email address on click.appcast.io. 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