Summary/objective
The professional RN Case Manager and Utilization Manager , in collaboration with the Provider and other healthcare team members, provides overall support to daily operations of the utilization management department - discharge planning, and utilization review; provides guidance and support for all care levels as indicated and related to utilization management - Emergency, pre-admit, admission through post-discharge follow-up. Assists in and provides primary resources to the Transfer Process as indicated. Works closely with the Regional Marketing Team to review referrals for potential admission into the Swing Bed program.
Salary Range: $115,107 to $138,129/year
Essential functions

• Demonstrate knowledge of Medicare and Medi-Cal, federal and state regulations, and third-party payers.
• Demonstrate knowledge of Swing Bed status in Critical Access Hospitals.
• Demonstrate successful guidance to the medical and nursing staff as to appropriate care level, diagnosis, treatment, and services related to medical necessity.
• Provide support to discharge planning pre-admission through post discharge follow up; organization wide patient experience support and demonstrates knowledge of the process and forms utilized in transferring patients to an outside facility.
• Provide support to utilization department related to pre-authorizations, continued authorizations, appeals, peer review process, and denials.
• Collaborate with the Regional Marketing Team reviewing referrals and accepting patients in collaboration with the Providers into the Swing Bed program.
• Provide support and participate with the Discharge Planner with daily huddle, interdisciplinary team, and UR Committee as indicated.
• Support quality and performance improvement activities, always respecting the confidentiality of patient records.
• Work with team to formulate, revise, review and implement policies and procedures in collaboration with the Nursing and Clinical Departments related to the utilization management, community resource/referral, and discharge planning process.
• Supports department wide maintenance of a strong culture of patient and clinical staff safety with balanced accountability.
• Demonstrates and ensures sustained department wide proficiency navigating through Orchard Hospital Health Information Systems (HIS) as appropriate, including CPSI, Lab, CPSI, Pyxis, Diagnostic Imaging System, Relias, and Orchard Hospital Policies and Procedures.
• Support Department standards of excellence to support nationwide benchmarks for Core Measure, Patient Experience, and Readmissions, as well as American Advanced Management Group's CARE Culture of Excellence.

Competencies

• Demonstrates effective communication with members of the health care team to achieve desired outcomes; Attends and participates in all required in-service training and mandatory meetings (75% staff mtg)

Supervisory responsibilities

• Supervision over discharge planning.

Work environment

• Be physically active for long periods without getting tired or out of breath.
• Be able to answer the calls
• Able to sit front of the computer for long amount of time.

Physical demands

• Use muscle for extend periods without getting tired.
• Coordinate movement of several parts of the body, such as arms, legs, while the body is moving.

Travel required

• Occasionally travel to Colusa Medical Center for meetings and training.

Required education and experience

• RN required, BSN or combination of equivalent degree and experience preferred.
• California Registered Nursing License current, activate and in good standing.
• At least 3 years case management, 1 year utilization review experience preferred.
• Inpatient hospital or resident facility and supervisory experience preferred.
• Current BLS certificate.

Preferred education and experience

• RN License