Overview

The RN Case Manager uses MCG criteria to evaluate the appropriateness of admissions, concurrent stay and readiness for discharge. She/he assures correct level of care: critical, telemetry, acute, observation, for all patients. The Case Manager provides an efficient, coordinated approach to clinical management, with an emphasis on discharge planning, care coordination and utilization management activities for select patient populations across the continuum of programs and services at AHMC. The essential functions of the RN Case Manager require constant collaboration with the Social Workers, Nursing staff, Financial Counselors, Medical Staff to coordinate the care of patients in a proactive manner. The position requires the full understanding and active participation in fulfilling the mission of AHMC- Anaheim Regional Medical Center. It is expected that the employee demonstrate behavior consistent with the core values. The employee shall support AHMC- Anaheim Regional Medical Center strategic plan and goals and direction of the performance improvement plan.

Responsibilities

• Conducts admission reviews and concurrent stays reviews using MCG criteria on all patients.
• Assures correct level of care: critical, telemetry, acute, observation, for all admissions. Work with physicians to assign/order appropriate designation and medical record documentation.
• Coordinated the care of patients in a proactive manner working closely with physicians, nursing staff, and ancillary departments.
• Conducts discharge planning assessments and coordinates discharge planning needs such as placement in long-term acute care facilities, Skilled Nursing Facilities, DME referrals, and Home Health services as needed.
• Works with patient or decision on discharge planning options and facilitates discharge planning on a proactive manner.
• Informs patient or decision maker on Medicare rights and gives IM notices on a proactive manner
• Consults with admitting office and patient financial services to assist with Medi-Cal and indigent care applications.
• Consults additional services to complete a safe and effective discharge plan, including physical therapy, social services, palliative care, interpreters, homeless advocates, patient financial services, behavioral health, etc.
• Calls clinical reviews to insurance companies and facilitates the approval of days.
• Communicates approval of days to CBO.
• Coordinates processes related to denial appeals.
• Identifies high-risk patient through rounding, maintains a list of possible high risk case-types.
• Develop and maintain community resource information/handouts for patients
• Coordinates family involvement and decision-making as needed
• Helps patients obtain a PCP if needed.
• Participate in Patient Care Rounds and Complex Case Meetings.
• Follow up as needed with high-risk patients via phone to ensure establishment with PCP, access, prescriptions, payer sources, self-management, etc.
• Other duties as assigned.

Qualifications

Bachelor’s Degree preferred, Associates Degree in Nursing. Minimum of two years direct patient care experience in designated area. In lieu of this experience, consideration will be made for staff with strong education and associated experiential background.

Effective written and verbal communication skills.

Highly developed sense of initiative and flexibility, along with good judgment and analytical skills.

RN License in the State of California required. Certified Case Manager preferred.

Hospital Description

ORGANIZATIONAL EXPECTATIONSA. Meets customer service expectations and AHMC Activities.1. Promotes a service culture – AHMC ARMC Customer Service Standards.2. Demonstrates the customer satisfaction standards set for the institution.3. Actively participates in ways to prevent customer complaints and dissatisfaction with services.4. Focuses attention and actions on what is best for the patient or customer.5. Attempts to identify all customer needs and tries to meet and/or exceed expectations.6. Interacts with all customers in a caring manner.7. Contact with others is polite and proactive.8. Promotes a positive teamwork environment.9. Creates closure after interactions.10. Communicates effectively in a positive, respectful and concise manner.

B. Demonstrates Core Values and supports Mission, Vision and Values and Code of Conduct.1. Can articulate and demonstrates support for organizational goals, the Mission and Vision of the Institution and the core values.2. Assures patient/family rights are respected and fulfills the Medical Center’s Patient Safety Philosophy.3. Maintains confidentiality of patient information and Medical Center business matters.4. Complies with all established policies and procedures.

C. Safeguards self/others and physical plant and equipment.1. Demonstrates and understands personal and department role in the security, health, life and safety plans.2. Demonstrates and understands role in the hazardous materials plan and can access information on MSDSs.3. Demonstrates and understands the role in the hospital emergency and disaster plan.4. Follows procedures for reporting faulty equipment or service problems.

D. Performance Improvement1. Participates in performance improvement activities.2. Understands and advocates AHMC initiatives.