Case Manager RN
POSITION SUMMARY
Promotes optimal, quality, cost-effective health care services to members throughout the continuum of care by coordinating, procuring, negotiating and managing the medical care delivery of members; working collaboratively with primary care providers, specialty and ancillary providers, in-patient case managers and discharge planners, and community-based organizations to meet members’ health care needs.
COMPLIANCE WITH REGULATIONS:
Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D and Special Needs Plan (SNP).
RESPONSIBILITIES
* Uses clinical judgment to review, monitor, and coordinate facility admissions, proposed surgical procedures, and specialty services requests by utilizing -approved clinical guidelines; reviewing clinical reports and records; determining medical necessity of proposed procedures; coordinating services at the appropriate level of care; communicating decisions to primary care practitioners.
* Monitors in-patient care and facilitates appropriate transition to out-patient or lower levels of care by referencing -approved clinical guidelines; reviewing member’s medical record; communicating with member, attending physician, hospital case managers and discharge planners, member’s primary care physician and other health care professionals to address member-specific needs; discussing cases with’s Medical Director and Case Managers regarding appropriateness of care and alternatives; arranging home health, referral to community-based resources, and other services to meet the member’s post-discharge needs.
* Coordinates case management and disease management programs by assisting primary care physicians and primary care site case managers in managing the care of members; assisting in the coordination of care post hospital discharge; reviewing covered benefits and alternative community and government based programs that may be available to member; identifying members in need of intensive case management and targeted disease-management initiatives; assisting IPA case managers and serving as a liaison between and IPAs; monitoring patient outcomes; analyzing existing policy and providing feedback as indicated.
* Serves as an intradepartmental “expert” or one or more product lines (e.g., Medi-cal, Healthy Families, Medicare), programs (e.g., CCS, CPSP) and/or functions (MEDecision) by developing a comprehensive knowledge base on each area of expertise; representing the department in interdepartmental and external meetings and forums regarding each area of expertise; educating and serving as a resource to staff members.
* Contributes to the team effort, maintains customer confidence, protects operations, and identifies potential quality issues by attending department meetings; giving and receiving feedback; performing other duties and assignments as requested; accomplishing related results as needed; keeping information confidential; communicating quality of care issues to CQI staff; providing requested data as required for QI studies; providing case-specific follow-up on an as-needed basis.
* Provides oversight in the appropriate use of emergency room services by reviewing selected emergency room claims for services provided beyond the initial evaluation; fostering relationships with staff at assigned hospitals to improve coordination of care at appropriate levels; identifying member and provider education opportunities regarding the appropriate use of emergency room services.
Education:
* Registered Nurse (RN) in CA (active status); current driver’s license and proof of auto insurance.
* Certification in utilization review and/or case management.
* Graduate from an accredited school of nursing.
* BS degree in nursing preferred
Experience/Skills:
* 2 years experience working in an acute care facility (ICU, emergency department, and/or medical/surgical unit) or 2 years experience in a managed care environment.
* Experience in case management, home health, medical claims review, discharge planning.
* Knowledge of managed care principles, CPT, ICD-9, HCPCS coding, experience with medical review criteria (Milliman & Robertson).
* Ability to communicate effectively verbally and in writing; exceptional telephone and customer service skills; ability to establish effective working relationships with physicians and medical professionals; ability to organize work effectively, determine priorities, and work well independently
Concurrent Review RN
POSITION SUMMARY
Assesses plans and coordinates optimal and timely care delivery for members along the entire continuum of care. Responsible for ensuring that ongoing services being utilized for patient care continue to meet the guidelines for that level of care. Participates in UM/CM quality and outcome monitoring.
COMPLIANCE WITH REGULATIONS:
Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D and Special Needs Plan (SNP).
RESPONSIBILITIES
· Reviews inpatient census on a daily basis and prioritizes cases based on high risk assignment, diagnosis, and available information. Obtains clinical information and reviews against nationally recognized guidelines.
· Review not meeting pre-certification guidelines are referred to Chief Medical Officer for determination.
· Conducts concurrent review by telephone or on-site.
· Applies Milliman USA guidelines to monitor, review and coordinate proposed services for adult and pediatric populations; and determine LOS; screen for under and over utilization.
· Forwards quality of care concerns to QI using criteria for identification of these cases; assist with QI studies; provides case-specific follow-up for pre determined cases.
· Collaborates with Provider of care, patient and significant others to arrange for alternative care and post-discharge needs.
· Utilizes pharmacy, ER encounter history, and admission history summaries to assist providers in developing a comprehensive discharge plan which includes member’s total potential discharge needs..
· Refers catastrophic and targeted disease management cases to appropriate Case Manager.
· Coordinates member’s continued care needs upon discharge from inpatient setting with assigned Case Manager.
· Reviews or assist in reviewing policies and workflow at least annually. Participates in QIA activities that would identify conditions appropriate for DM efforts.
· Under the direction of department manager researches and assist 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 regarding each area of expertise.
· Functions as a resource to internal and external customers by developing relationships with staff at assigned hospitals, clinics, and delivery care providers in order to facilitate and improve coordination of care. Provides education to members and providers on available resources to members. Offers assistance to peers when needed.
Education:
· Graduate from an accredited school of nursing.
· Registered Nurse (RN) in CA active status); current driver’s license and proof of auto insurance.
· BSN degree in nursing and certification in utilization review and/or case management preferred.
Experience/Skills:
· 3 years experience working in an acute care facility (ICU, emergency department, and/or medical/surgical unit) and 1 year experience in a managed care environment or hospital discharge planning or high risk management or outpatient clinic.
· Inpatient discharge planning and high risk management experience or outpatient referral management preferred.
· Working knowledge of Microsoft Word programs.
· Knowledge of managed care principles, CPT, ICD-9, HCPCS coding, experience with inpatient and outpatient medical review guidelines (Milliman USA,Interqual).Familiar with Medi-Cal, Medicare. Familiar with Web based standard of care sites i.e. NIH, ACOG.
· Ability to communicate effectively verbally and in writing; exceptional telephone and customer service skills; ability to establish effective working relationships with physicians and medical professionals; ability to organize work effectively, determine priorities, and work well independently.
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.
Company Name Nurse Resolutions
Job Category Healthcare
Location Chula Vista, CA
Position Type Full-Time, Employee
Experience 0-1 Years Experience
Date Posted September 26, 2008
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