Overview

The Case Manager leads care coordination throughout hospital levels of care. In this role the Case Manager completes assessments and transition care planning that reflects the wishes and needs of the patient and their family. This position also assists physicians and finance with the management of resource utilization through the use of medical necessity criteria. 

Responsibilities

Completes medical necessity criteria for both inpatient and outpatient visits, documenting the reasons when the patient status is not supported in the database and reporting discrepancies during weekday morning huddles.

Completes assessments and discharge plans for inpatients. Provides consultation for outpatient and observation patient stays when requested. Assists with discharge planning for these patients as needed.

Builds provider networks and community resources and provides updates to the clinical team.

Assists in the case management functions of the preoperative preparation and discharge planning for Inpatient or outpatient surgeries, specifically the Total Joint Program as able.

Leads morning huddles focusing on patient status, expected LOS and providing the tentative plan for discharge.

Completes LACE tool for Inpatients and reports Lace scores to hospitalist group for furthering discussions regarding palliative care and readmission reduction.

Role models values and actively applies patient engagement strategies; documents information on the white boards including what matters to the patient. Completes the MY Plan for all inpatients and uses the "journey" program to provide discharge planning education to patients and their families.

Conducts readmission interviews with readmitted patients to determine the reasons for returning to the hospital. Bases care plan on information gleaned from interview. Completes follow-up phone calls for high risk patients as time allows.

Assists with requests for clinical information for medical necessity insurance reviews and arranges peer to peer calls when an appeal is warranted.

Qualifications

Education: Graduate of an accredited RN programExperience: At least 2 years clinical patient care on a medical surgical unit, specialty unit, or currently working in a case management setting.Licenses & Certifications: Licensed RN in the State of California, certification in Case Management or Utilization Review at hire or within 3 years of hire if no experience in case management.Required Skills & Knowledge: Good written and verbal communication skills. Ability to manage priorities and workflow. Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm. Ability to deal effectively with a diversity of individuals at all organizational levels. Good judgement with the ability to make timely and sound decisions. Proficiency with computers and electronic forms of communication.