Description

Under limited direction, to assess, plan, coordinate, implement, facilitate, and monitor the delivery of required services, treatments, and resources for assigned patients of Santa Clara Valley Healthcare (SCVHC).

Typical Tasks

• Reviews and assesses assigned patients' medical and personal history, current status, psychological needs; diagnosis, prognosis, treatment plan and payer source;
• Interviews patient, family, and/or caregivers regarding home environment and support, prior level of function, financial resources, social supports and other factors likely affect care and/or discharge plan;
• Provides medical treatment education to patient, patient's family and other medical staff;
• Reviews and assesses, on an ongoing basis, assigned patients' charts for adherence to treatment plans;
• Acts as a liaison to and confers with staff of various disciplines to ensure completion of services and treatments with appropriate timeframes;
• Secures and negotiates resources to ensure multiple health care needs are met;
• Communicates with insurance companies and providers; prepares clinical documentation as required by payer source; justifies level of care and appeals denials for continued hospital stay, medical services, and dispositional services; provides coverage updates;
• Identifies and resolves situations and barriers causing delays in service, treatment, or discharge; and utilizes creativity in developing solutions;
• Intervenes when necessary to ensure the care provided is necessary and performed in a timely manner to avoid loss of revenue to the hospital and potential denial of payment by the provider;
• Researches, communicates and recommends, when appropriate, alternative, more cost effective, service delivery;
• Participates in interdisciplinary patient care conferences and patient team rounds;
• Confers with appropriate individuals in other specialty areas regarding patient treatment and service aspects;
• Documents patient progress;
• Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physicians, nursing staff, social services and other healthcare providers and agencies; identifies potential difficulties in community reintegration where appropriate;
• Coordinates and ensures procurement of required patient medical equipment and may train patient's support system in use;
• Collaborates with other staff or assists with scheduling follow up care, as necessary;
• Serves as member of various hospital committees;
• Represents SCVMC in State hearing process for those patients refused admittance to a skilled nursing facility;
• Researches criteria within utilization computer system in order to monitor inpatient level of care and to facilitate and assist doctor-to-doctor and peer-to-peer review between Hospital and health plan;
• Keeps abreast of payer guidelines and specific licensure requirements;
• Assists in the hiring process and training of new staff;
• Participates in special project development and implementation;
• May be assigned as a Disaster Service Worker, as required;
• Performs other related duties as assigned.

Employment Standards

Sufficient education, training and experience to demonstrate possession and direct application of the following knowledge and abilities.
Training and Experience Note: The required knowledge and abilities are attained through two (2) years of full-time experience comparable to a Clinical Nurse II in the County of Santa Clara in an acute hospital setting.
Special Requirement:
Graduate of an approved nursing program and licensed as a Registered Nurse (RN) in the State of California prior to appointment.
Possession of a Bachelor of Science in Nursing (BSN) and/or current patient case management experience is desirable.
Knowledge of:

• Medical terminology used in diagnosis, level of care, disease continuum, and treatment;
• Patient evaluation, assessment and communication techniques;
• Federal and State health care laws and regulations appropriate to the operation of California hospitals;
• Care management delivery systems;
• Various acute care hospital specialties;
• Basic training techniques;
• Financial processes for various private and public funding sources;
• Private and governmental insurers and medical assistance programs;
• Available alternative patient services and treatments;
• Acute care hospital operations, organization, systems and service areas;
• Record keeping and reporting procedures;
• Computer systems that provide evidence-based clinical criteria and common office computer applications;
• Various criteria for determining level of care and current standards in medical, therapy, and nursing practice.

• Communicate orally and in writing in an effective, tactful, and assertive manner, including with distressed or emotional individuals;
• Keep abreast of, understand, and interpret healthcare laws, regulations, and procedures;
• Work independently and under pressure, meet deadlines, adapt to varying circumstances and use sound judgement in the performance of duties;
• Develop and maintain effective working relationships with patients, families, peers, medical professionals, and all contacted in the course of work;
• Reason logically and creatively, and utilize a variety of analytical techniques to resolve complex and specialized issues;
• Educate and train others;
• Perform research, evaluate data, and make recommendations;
• Work effectively and in cooperation with other organizations, departments and personnel;
• Keep abreast of current, available, alternative treatments and services;
• Resolve complex interdisciplinary problems in an expeditious and effective manner.

Physical Requirements

Ability to work irregular hours, weekends, and holidays, as necessary.