RN High Risk Case Manager

Description

Job Type:  Full-Time

Job Description:  OVERALL JOB PURPOSEResponsible for utilization and case management activities. Manages medical costs through timely prospective concurrent and retrospective activities. Assists the Physician in facilitating and communicating discharge needs and plans to the interdisciplinary staff members and patients.MINIMUM JOB QUALIFICATIONS AND REQUIREMENTSRegistered Nurse with current license in Nevada.BS in Nursing or other health related area preferred.One year of experience in utilization review quality assurance discharge planning or other cost management program required.Two years experience in hospital-based nursing required. Charge nurse or critical care experience preferred.ESSENTIAL JOB DUTIES AND RESPONSIBILITIES-Responsible for quality and continuous improvement within the job scope.-Responsible for all actions/responsibilities as described in company controlled documentation for this position.-Contributes to and supports the corporation’s quality initiatives by encouraging team and individual contributions toward the corporation’s quality improvement efforts.-Works to contain health care costs and maintains high quality medical delivery system through the principles of pre-admission review.-Reflects Nationally Recognized Care Guidelines or Medicare Coverage Guidelines (SNF facilities) for appropriateness of admission and level of care.-Initiates the discharge planning process by contacting the member and/or patient designated caregiver or legal guardian to discuss the member’s discharge needs and initiate a global discharge plan.-Knowledgeable in the application of NRCQ collaborating with interdisciplinary team members and NRCQ in the delivery and managing of patient care.-Addresses medical and non-medical variances/quality identifies and accurately documents and reports according to company policy and procedures.-Collects accurate and timely health care data and adequately documents patient related issues (prior authorization concurrent review alternative care discharge planning referrals high risk department) and provider related issues.-Performs onsite concurrent review as stipulated by the guidelines policies and procedures.-Promotes alternative care programs and researches available options including costs and appropriateness of patient placement; recommends coordinates and educates patients and providers on these options.-Reviews medical records documentation throughout the inpatient stay and revises the discharge plan as indicated by the members condition; works with hospital discharge planners and social workers in early identification of potential home care candidates.-Identifies COB and/or subrogation cases.-Contacts the Nursing Services Management Team Hospitalist IPN Medical Director or designee as needed for unresolved issues variances in length of stay or complex discharge needs.-Initiates quality referrals using the quality referral process when indicated.-Makes appropriate referrals to providers prior to discharge including but not limited to home health care durable medical equipment infusion other facilities.-Initiates State Certification (PASSAR sceens) for transfers to skilled nursing facilities and long term care facilities if indicated.-Submits reports charts audits information and logs as required.-Performs telephonic concurrent review to long term acute acute rehab and skilled nursing facilities within the local service area as assigned by manger using the same guidelines as on-site reviews.-Knowledgeable in HIPAA guidelines to ensures confidentially in all aspects of communication.-Supports the mission vision and values.-May be required to participate in rotation of on-call assignments. OTHER JOB DUTIES AND RESPONSIBILITIESPerforms others duties and responsibilities as assigned.Willing to work overtime and on weekends as needed.Meet with external groups as needed.WORKING CONDITIONSDuties are performed in primarily a hospital environment environment. PHYSICAL REQUIREMENTSLight to moderate work requiring the ability to carry moderate weight objects. Ability to verbalize through speaking hearing and seeing is vital to carrying out position requirements. Ability to move about rapidly (majority of work is walking). Ability to utilize a cellular/radio type phone and pager is necessary.We are proud to be an EEO/AA employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing.