Description

POSITION SUMMARY

Responsible for health care management and coordination of Community Health Group members in order to achieve optimal clinical, financial and quality of life outcomes. Ensures access to health care in accordance to company policies. Works with members & facility case managers to create and implement an integrated collaborative plan of care. Coordinates and monitors Community Health Group members progress and services to ensure consistent cost effective care that complies with Community Health Group policy and all state and federal regulations and guidelines.

COMPLIANCE WITH REGULATIONS

Works closely with all necessary departments to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures, applicable state and federal regulations, contractual requirements and accreditation standards.

RESPONSIBILITIES

• Monitors in-patient care and facilitates appropriate transition to out-patient or lower levels of care by referencing CHG-approved clinical criteria for utilization management decisions; reviewing members medical record; communicating with member, attending physician, hospital case managers and discharge planners, members primary care physician and other health care professionals to address member-specific needs; discussing cases with CHGs Chief Medical Officer and Case Managers regarding appropriateness of care and alternatives; arranging home health, referral to community-based resources, and other services to meet the members post-discharge needs.

• Reviews inpatient census on a daily basis and prioritizes cases based on department policies, protocols, and guidelines.

• Conducts concurrent review predominately on-site and retrospective review by reviewing facility medical records.

• Reviews all cases that do not meet clinical criteria for utilization management decisions with the Chief Medical Officer for determination.

• Utilizes pharmacy, Emergency Room (ER) encounter history, and admission history summaries to assist providers in developing a comprehensive discharge plan which includes members total potential discharge needs.

• Coordinates members continued care needs upon discharge from inpatient setting with appropriate CHG Case Manager.

• Participates in Quality Improvement Activities (QIA) activities. Forwards quality of care concerns to the QI Department and provides case-specific follow-up for pre-determined cases.

• Under the direction of department manager, researches and assists in the implementation of processes surrounding workflow and internal guideline development designed to enhance member outcomes and increase customer satisfaction.

• Attends department meetings; provides feedback for existing processes; maintains patient confidentiality; represents department in interdepartmental and external meetings and forums on request.

Qualifications

Education

• Graduate from an accredited school of nursing.

• Unencumbered Registered Nurse (RN) license in CA; current drivers license and proof of auto insurance.

• BSN degree in nursing and certification in utilization review and/or case management preferred.

PHYSICAL REQUIREMENTS

• Prolonged periods of sitting at desk; intermittent standing, walking, bending, stooping, lifting 10 lb. or less.

• May be necessary to work and attend meetings outside of facility or normal business hours.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.

**Must have current authorization to work in the USA**

Community Health Group is an equal-opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and training. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action.