Job Title: Case Manager

Job Summary: The LVN or RN Case Manager (CM) performs a wide variety of tasks and functions. These include utilization review, discharge planning, care coordination and variance management to assure the delivery of necessary services, efficient patient progression, and payment for the services provided. Serves as a liaison between the designated Hospital and payers to ensure financial coverage for the patient. Coordinates resources and services for the patient/family in response to individual needs and fiscal responsibilities. Works with the multidisciplinary team to ensure coordination of patient care and wise utilization of resources. Documents case management activities in the patient record and in the required information system. The LVN or RN CM reports to the Director/Manager of the department.

Essential Job Duties:

• Applies appropriate clinical knowledge in order to identify patient needs and effectively communicate medical necessity and treatment plan to payers.
• Reviews concurrently and retrospectively all inpatients for appropriateness of admission, level of care, and length of stay utilizing InterQual criteria.
• Collaborates with the multidisciplinary team to develop, coordinate, implement and evaluate patient care.
• Identifies and anticipates discharge needs and collaborates with the multidisciplinary team to ensure that each patient’s discharge needs are assessed, planned for, and addressed in a timely manner.
• Educates and collaborates with the multidisciplinary team including physicians and patients/families regarding utilization issues, documentation of medical necessity, discharge options, and community resources.
• Anticipates barriers to efficient and effective patient progression by identifying clinical, operational, financial and social issues affecting patient outcomes and intervening to address these issues.
• Estimates the expected length of stay (ELOS) based on the knowledge of patient cases and interactions with the interdisciplinary team. Communicates expected discharges to the unit charge nurse, patient unit and family.
• Identifies patients at risk for extended lengths of stay, readmission, and complex discharge needs.
• Identifies and documents Avoidable Days using the data to address opportunities for improvement.
• Prevents denials and disputes by communicating with payers and documenting relevant information.
• Promotes prudent utilization of all resources (fiscal, human, environmental, equipment, and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes.

Behavioral Standards:

• Exhibits customer and service-oriented behaviors in everyday work interactions.
• Demonstrates a courteous and respectful attitude to internal workforce and external customers.

Communication/Knowledge:

• Time management and priority setting skills.
• Must have the ability to manage multiple complex activities with tight deadlines.
• Ability to design, develop, and implement programs and care coordination with initiative and creativity.
• Skilled in working with a wide range of personalities and utilizes sound judgment in working with all members of the team, patients/families, and payer representatives.
• Able to listen, understand, problem-solve, and carry-out duties to ensure the optimal patient care outcomes.
• Professional dress and demeanor.
• Able to remain poised under stress.
• Able to use IT systems in an accurate and proficient manner.

Collaboration/Teamwork:

• Contributes toward effective, positive working relationships with internal and external colleagues.
• Demonstrates cooperation, flexibility, reliability, and dependability in all daily work activities and a willingness to collaborate with others for the good of the customer and the organization.

Education/Experience:

• Associates or Bachelor’s degree in Nursing preferred, Master prepared a plus.
• Minimum of 1-3 years in Case Management Acute Care Setting

Licensure/Certifications:

• Current LVN or RN licensed in good standing by the California Board of Nursing
• Current BLS for Health Care Provider card.
• Accredited Case Manager (ACM) or Certified Case Manager (CCM) a plus.

ADA/Physical Demands:

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant in order to be considered.
• Required to stand; walk; sit; use hands to fingers, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl; talk and hear; and may taste and smell. The employee is regularly required to lift, push and/or pull weights in excess of 10 pounds, with assistance. Visual abilities, auditory abilities, must be intact to perform duties