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

Case Manager

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 ring an understanding of the clinical process of assessment, planning, implementation, and evaluation to the process of case management.

Some of the major duties of a Case Manager include: Documenting patients' case management plans and on-going activities; Identifying patients 'insurance coverage or other sources of payment for services; Identifying and addressing patient risk factors and/or obstacles to care; Identifying patient needs, current services, and available resources, then connecting the patient to services and resources to meet established goals; Communicating the care preferences of patients, serving as their advocate, and verifying that interventions meet the patient's needs and treatment goals; Screening patients and/or population for healthcare needs; Developing a patient-focused case management plan; and Educating the patient/family/caregiver about the case management process and evaluating their understanding of the process.

Some of the major duties of the Case Manager overlap into inpatient duties including: Concurrent review of all patients to validate that the appropriate patient status is assigned upon admission and prior to discharge; InterQual or MCG reviews are completed within 24 hours of admission; Observation patients are effectively care managed on a daily basis; and Facilitate throughput and timely discharges throughout inpatient level of care.

Essential Duties

• Clinical Care Coordination
• Able to effectively manage a case load, supporting up to 100 commercial outpatients.
• Utilizes the on line 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, as supported by the ambulatory care coordinator.
• Analyze and interpret data in collaboration with patient, family, physician, health care team to develop a plan of care, and as supported by the ambulatory care coordinator.
• Ensures that a specific plan of care is in place for all patients. As supported by the ambulatory care coordinator, timely completion of all tasks, from the plan of care. Provide coordination of care such as schedule patients' appointments, arrange transportation, etc. as outlined in policy and procedures.
• Actively participates in interdisciplinary meetings and team huddles.
• Answer phone calls from providers, facilities, or patients, related to the status and processing of requests received from ambulatory care management nurse.
• Assess ongoing discharge planning needs and documents is computer system as changes to the plan occur.
• Demonstrates collaborative working relationship with social workers to ensure patient psychosocial needs are met.
• Demonstrates collaborative working relationship with care team members, including pharmacy, behavioral health, field team, office staff, and facility staff.
• Completes Medicare One Day Stay forms timely.
• Completes disposition form 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 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.
• Makes appropriate referrals to supervisor or Medical Director, communicating accurate clinical information.
• Participates in guideline (MCG and/or InterQual) 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 med group quality improvement processes and helps identifies 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.
• 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 to address educational needs to ensure a safe discharge plan.
• Work with patient/family to learn Self-Management methods for on-going 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.
• Complete case management care plans, including tasks and interventions, that effectively prevent ER Visits, Hospital admissions, or Re-admissions.
• Maintains awareness of current managed care contract requirements.
• Coordinate the management of all in-patient activities/processes, including but not limited to 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 in-patient services.
• Performs and documents (InterQual &/or MCG) guideline-based assessments: A) upon admission, B) upon a change in level of care, C) every 2 days, and D) upon discharge.
• Participates in InterQual and/or MCG competency testing.
• Perform telephonic, and if appropriate, on-site initial/concurrent review on identified in-patient members. Direct pertinent clinical information/questions to contracted in-patient Hospitalists, PCPs, Medical Director and/or Director of Health Services.
• Collaborate 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.
• Able to prioritize clinical reviews, caseloads, census loads, and assignments.
• Other duties as requested or assigned.

Required Qualifications:

• Req Associate's Degree Nursing
• Req 5 years Clinical experience
• Req 2 years Ambulatory case management or utilization review experience within the last three years
• Req Ability to work independently with minimal supervision, exercising judgment and initiative.
• Req Ability to manage multiple tasks with effective prioritization.
• Req Process oriented.
• Req Good computer skills.

Preferred Qualifications:

• Pref Bachelor's degree Nursing
• Pref 2 years Experience in an HMO/IPA/Managed care setting
• Pref 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:

• Req Registered Nurse - RN (CA DCA)
• Req Basic Life Support (BLS) Healthcare Provider from American Heart Association
• Req 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)