Job DescriptionWhat will you be doing in this role?
The Case Manager is responsible for the case management of patient while hospitalized and upon discharge from various care settings. In collaboration with the Inpatient Specialty Program (ISP) hospitalists, the Case Manager will assist patients from the time they are admitted until they are discharged from the hospital by assessing their needs, coordinating care, communicating with health plans, including concurrent review to determine the appropriateness of services rendered and to ensure that quality care is delivered in a cost-effective manner.
Primary Duties and Responsibilities
- Meets with patients within 24 hours of admission and conducts an initial assessment.
- Consults with assigned hospitalist each day during morning rounds regarding disposition planning and appropriateness for each day of patient's stay.
- Reviews with hospitalist the patient's admission and continued stay for medical necessity, appropriateness of care and level of care. Use Milliman and Interqual guidelines as necessary.
- Plans for discharges and care assessments.
- Submits necessary clinical information to the health plan using the accepted format (MIDAS or telephonic) and coordinate health plan communication with assigned hospitalist as appropriate.
- Coordinates with nurse practitioner and case manager assigned to the SNF's for continued review and follow up.
- Communicates transition of care to the member or responsible party including: i) Transition process and what to expect ii) Changes in health status and the care plan iii) Staff who will be handling issues, questions, concerns, i.e. Case Manager.
- Authorizes all appropriate services based upon covered benefits and necessity of care provided in the: a) Member's home or residence b) Acute Care c) Skilled Nursing Facility d) Rehabilitation Facility e) Home Health Care f) Custodial Care facility or Board and Care Facility.
- Coordinates discharge planning and alternative treatment plans with PCP/hospitalist/specialist as appropriate.
- Secures outpatient follow-up appointments and scheduling tests or outpatient procedures with appropriate health care providers.
- Refers to Ambulatory Case Manager for those patients identified that need oversight of outpatient care and compliance to avoid unnecessary readmissions.
- Coordinate referrals and secure appointment with various CSMNS disease management programs.
QualificationsJob qualificationsEducation- Bachelor's Degree Graduate of an accredited school of nursing required
Work Experience- 3 years nursing experience required
- 1 year 1-2 years of previous experience in case management in the outpatient setting required
Licenses and Certifications- State License current California RN or LVN licensure required
- Certified Case Management RN or LVN preferred
