The RN Case Manager will provide daily care coordination with concurrent review for patient in the hospital or Skilled Nursing Facilities (SNF) in person or telephonically. This position will also provide case management to patients who are admitted to the hospital and those patients who may need to be enrolled in ambulatory case management. The RN case manager will be responsible for identifying (California Children Services) CCS cases, handle transfers, and retro reviews. Works as part of an interdisciplinary care team coordinating care and collaborating with social work, ambulatory case management, and Regional Medical Directors, Hospitalist, the hospital nursing personnel, and with the physician in the clinic. The RN Case Manager will be expected to perform assessments and use the appropriate guidelines to ensure the patient is receiving the appropriate level of care.
- Graduation from an accredited nursing program.
- Current valid License as a Registered Nurse through the California Board of Registered Nursing; Bachelor’s degree in nursing, or another health or human services field with the appropriate licensure preferred.
- Experience in and willingness to be part of multi-disciplinary team.
- Experience with physically or mentally impaired adults and/or geriatric population.
- Three years RN experience in public health nursing, acute care, case management and/or home health care required; minimum of 2 years of managed care experience in case management with focus in inpatient and/or outpatient ambulatory care preferred.
- Bilingual in English and Spanish preferred.
- Responsible for daily concurrent reviews, retro reviews, discharge planning, pre-certification/prior authorization request review, and ensures patients meet appropriate level of care based on acceptable evidence-based Clinical Criteria(s). (Interqual and / or Milliman)
- Follows established policies, procedures, workflows, and desktop procedures of the department.
- Effectively and efficiently manages patients throughout the continuum of care.
- Works collaboratively with hospitalists, hospital partners, and care teams to provide holistic patient care that is focused on high quality in a cost effective way.
- Develops a working relationship with the hospital case managers, health plan, clinics, hospitalists and other governing entities.
- Works with hospital discharge planners and assists in the coordination of support services.
- Rounds and reports daily with Regional Medical Director, RN Leadership, and hospitalists to collaborate on Plan Care and Discharge Plan.
- Rounds and reports daily catastrophic cases (>10days) and full, dual, and shared risk patients to RMDs and RN Leadership
- Attends Joint Operation Meetings (JOM) meetings and various community meetings as needed.
- Responsible for the daily review and processing of referral authorizations in accordance to turnaround time (TAT) standards set by ICE/Health Plan requirements.
- Assists in performing and documenting patient outreach telephonic and/or face to face to ensure safe, appropriate discharge planning to reduce the likelihood of readmissions and responsibilities includes but not limited to PCP appointments, ensure DME Home Health is ordered, referring for social barriers for referrals to social workers.
- Performs other related duties as assigned.
- Responsible for performing necessary assessments to provide adequate patient care.
- Responsible for formulating an appropriate and safe transition of care plan to the next level of care.
- Responsible for ensuring discharge plan is obtained and communicated / forwarded to PCP and/or next level of care provider.