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Case Manager Utilization RN
Sign-On Bonus eligible position!
Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. 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 the Multidisciplinary team, multitask and in a fast pace environment.
• Plans, develops, assesses & evaluates care provided to members.
• Collaborates with physicians, other members of the multidisciplinary health care team & patient/family in the development, implementation & documentation of appropriate, individualized plans of care to ensure continuity, quality & appropriate resource use.
• Recommends alternative levels of care & ensures compliance with federal, state & local requirements.
• Assesses high risk patients in need of post-hospital care planning.
• Develops & coordinates the implementation of a discharge plan to meet patient's identified needs.
• Communicates the plan to physicians, patient, family/caregivers, staff & appropriate community agencies.
• Reviews, monitors, evaluates & coordinates the patient's hospital stay to assure that all appropriate & essential services are delivered timely & efficiently.
• Participates in the Bed Huddles & carries out recommendations congruent with the patient's needs.
• Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, & 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 & non-KFH facilities.
• Acts as a liaison between in-patient facility & referral facilities/agencies & provides case management to patients referred.
• Refers patients to community resources to meet post hospital needs.
• Coordinates transfer of patients to appropriate facilities; maintains & provides required documentation.
• Adheres to internal & external regulatory & accreditation requirements & compliance guidelines
including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA & DOL.
• Educates members of the healthcare team concerning their roles & responsibilities in the discharge
planning process & appropriate use of resources.
• Provides patients with education to assist with their discharge & help them cope with psychological
problems related to acute & chronic illness.
• 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.
• Reviews, analyses & identifies utilization patterns & trends, problems or inappropriate utilization of resources & participates in the collection & analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
• Coordinates, participates & or facilitates care planning rounds & patient family conferences as needed.
• Participates in committees, teams or other work projects/duties as assigned.
• Two (2) years clinical experience as an RN in an acute care setting required.
• Completion of an accredited RN training program that allows graduates to take RN license exam.
Licenses, Certifications, Registrations
• Current California RN license required.
• AHA BLS.
• 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 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.
• Bachelor's degree in nursing or healthcare related field preferred.
• Case Management Experience Preferred
• Will be required to work every fourth weekend, holidays per Union contract.
• Will be trained for all areas, Inpatient and ED
Job Category: Nursing Licensed & Nurse Practitioners
- Electronic Medical Record
- Disease Management
- Long Term Care
- Registered Nurse
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Job ID: 2321656463
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