RN Case Manager

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RN Case Manager

Job Overview

RN Case Manager

Overview:

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RN - Case Manager - is a collaborative practice including patients, caregivers, nurses, social workers, physicians, payers, support staff, other practitioners and the community.
  • The Case Management process facilitates communication and care coordination along a continuum through effective transitional care management and utilization management.
  • Recognizing the patient's right to self-determination, the significance of the social determinants of health and the complexities of care.
  • The goals of Case Management include the achievement of optimal health, access to services, advocacy, appropriate utilization of resources, collaboration with post-acute care providers to ensure patient's needs are met in the community, and to provide timely clinical reviews to payers.
  • The Care Manager utilizes the following processes to meet the patient's individual healthcare needs:  assessment, planning/intervention, implementation, care coordination, utilization management, monitoring, evaluation of the plan of care and communication. 
 
Duties:
Assessment: The Care Manager will collect in-depth information about a persons’ situation and functional status to identify individual needs in order to develop a comprehensive plan of care that will address the patient’s needs.
  • The Care Manager will identify both present and possible future needs of the patient and family, which may affect the plan of care and the patient’s well-being.
  • This assessment will include age-specific physical, psychosocial, environmental, financial, and health status expectations
Planning: The Care Manager will identify specific objectives, goals and actions, as identified during the assessment process.
  • Acting as a patient advocate the Care Manager will collaborate with the physician, the patient & family, and members of the healthcare team, to formulate a shared plan of care.
  • Educating the patient, the family or caregiver, and members of the health care delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, case management, etc., so that timely and informed decisions can be made.
  • Goals and time frames for goals, appropriate to the patient, will be set
Implementation: Executes specific interventions that will lead to accomplishing the goals and timeframes of the shared plan of care,
  • Works effectively with the healthcare team to determine the necessary steps to achieve the plan of care.
  • Problem solving techniques will be applied to the implementation process.
  • The Care Manager will utilize knowledge of alternative funding sources, benefit plans, and contractual information to promote appropriate quality, cost effective care for members throughout the healthcare continuum
Coordination: Organizes, coordinates, provides, modifies or obtains appropriate authorizations, utilizing appropriate utilization review and evidence of coverage guidelines, to accomplish the patient’s goals.
  • Initiates and communicates with the patient and family, physicians, healthcare members, community and payor representatives.
  • Facilitates continuity of care throughout all access points involving Health Plan, discharge planners, physicians and other appropriate staff

Monitoring: Obtains sufficient information from all relevant resources in order to determine the effectiveness of the plan of care, and services provided.
  • Manages a caseload of high risk, complex needs and/or catastrophic patients

Evaluation: At appropriate and repeated intervals, assesses and reassesses the patients’ progress.
  • If progress is static or regressive, determines the reason and encourages the appropriate interventions to obtain optimal outcomes.
  • The Care Manager will modify the plan of care, as necessary, in coordination with the healthcare team, family members, and providers
Communication: Communicates both verbally and electronically with the patient and the healthcare team.
  • Appropriately documents of the plan of care, outcomes, statistical reporting, logs, and files abiding to departmental, legal and regulatory requirements
Utilization Management: The Care Manager will provide prospective, retrospective and concurrent utilization reviews as required.
  • Ensure timely communication to health plans regarding authorizations, denials, and peer-to-peer physician reviews. 
  • Escalates to department leadership and physician advisor as appropriate
  • Admission reviews are conducted within one business day of admission
  • Continued stay reviews are provided daily for all HMO and Commercial payers
  • Continued stay reviews are provided upon admission until the patient meets Acute IP LOC OR a secondary reviewer deems patients requires acute IP care for all Medi-Cal FFS beneficiaries
  • Daily clinical reviews will be documented for all pending and restricted Medi-Cal patients
  • Focuses on patient class determination and escalates all cases with a patient class mismatch
  •  Performs continued stay reviews on current patients and communicates clinical information to payers in a timely manner such that the patient’s hospital days are authorized at the level of care being provided
  • Management of denials while patients are in hospital to ensure peer to peer physician reviews are completed to prevent denials
  •  Identifies, reports cases and problems appropriate for secondary review to Director or Physician Advisor
  • Collaborates with CDI. Advocates for appropriate provider documentation to accurately reflect patient severity of illness and risk
 
Required qualifications:

Bachelor's Degree in Nursing
  • All Registered Nurses without a minimum of a Bachelor’s degree in Nursing must obtain a Bachelor’s degree in Nursing or higher within 3 years of hire
  • California State Registered Nurse License in good standing
  • 2 years experience in Healthcare related field (Acute, Ambulatory, Post-Acute, etc.) 
  • 2 years experience in Case Management (Care Coordination or Utilization Management) or successful completion of the Transitions in Practice (TIP) program for Care Manager. TIP candidates must have experience in same type of nursing unit in which the CM position is available
  • Demonstrated problem solving skills
  • Strong verbal communication and listening skills
  • Demonstrated customer service skills
  • Excellent collaboration and team building skills
  • Effective interpersonal skills
  • Assumes personal responsibility for actions
  • Demonstrated ability to maintain confidential information
  • Demonstrates excellent judgment and decision making skills
  • Excellent organizational skills
  • Highly thorough and dependable
  • Friendly and service-oriented
  • Maintains a high degree of professionalism
  • Maintains composure under pressure
  • Performs work independently with minimal supervision
  • Possesses flexibility to work in a fast paced, dynamic environment
  • Seeks to acquire knowledge in area of specialty
  • Demonstrated time management and priority setting skills
  • Demonstrates a high commitment to quality
  • Basic computer skills, Word, Excel, Access, PowerPoint, etc.
  • Knowledge regarding State and Federal regulations
  • Knowledge of the principles and practices of Case Management and Healthcare
  • Knowledge of physical and psychological characteristics of disease processes, recognizes potential clinical problems, and recommends intervention in a preventative, pro-active way
  • Ability to access and evaluate community resources to meet patient’s needs
  • Knowledge and skills necessary to communicate with third party payers

 

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