Daily operational responsibilities include utilization management, discharge planning, referral facilitation and/or collaboration with hospital- based case managers/physicians to move patients to appropriate level of care. Provide Care interdisciplinary team communication about the hospital stays. This is an on-sight hospital- based function requiring the Case Manager RN to travel to 1-2 hospitals daily, work in collaboration with the hospitalist to improve outcomes with Observation stay, long discharge plans and prevention of readmission.
Primary responsibility for case management includes discharge planning, improved transitions of care, and utilization management of long length hospitalized health plan members. Ensure members receive quality medical care in the most appropriate setting. Performs the following on a daily basis; 1) performs patient assessment of all major domains using evidence based criteria (physical, functional, financial and psychosocial); 2) develop individualized discharge plans that involve provider, patient and caregiver goals for successful transitions of care; 3) implement discharge plan involving health care resources across the continuum; and 4) monitor and report variances that may challenge timely quality care.
Primary Responsibilities:- Assess, plan and implement care strategies that are individualized by patients and directed toward the most appropriate, lease restrictive level of care
- Utilize both company and community-based resources to establish a safe and effective case management plan for hospitalized members
- Collaborate with patient, family and health care providers to develop an individualized plan of care that encompasses both acute care episode and post hospital discharge plan
- Communicate with all stakeholders the required health related information to ensure quality coordinated care and services are provided expeditiously to all hospitalized members
- Advocate for patients and families as needed to ensure the patient's needs and choices are fully represented and supported by the health care team
- Utilize approved clinical criteria to assess and determine appropriate level of care for hospitalized members
- Understand insurance products, benefits, coverage limitations, insurance and governmental regulations as it applies to the health plan
- Understand role and how it affects utilization management benchmarks and quality outcomes
- Coordinate hand-off of care to primary care provider
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:- High School diploma and/or equivalent
- Active unrestricted Nevada RN license
- Ability to obtain CCM certification within two years of employment
- 2+ years of varied clinical experience in a hospital or clinical setting with an emphasis on case management
- Experience in a managed care organization
- Knowledge of utilization management in a managed care environment
- Independent case management knowledge and skills to formulate plans of care without direct supervision
- Understanding of spectrum of alternative delivery systems
- Ability to use computer-based programs and applications
- Demonstrated initiative toward problem solving without direct supervision
- Proven solid organizational, written, oral computer skills
- Proven excellent problem-solving skills
- Proven ability to negotiate with professionals, patients, and caregivers
- Critical Thinking: Proven ability to integrate guidelines/tools to negotiate most effective plan of care. Formulate plans that incorporate the health plan benefits, community services and patient self-direction
- Valid Nevada driver's license and maintain personal auto insurance coverage
Preferred Qualifications:- Bachelor's degree
- Knowledge of Interqual or Milliman guidelines
- Recent Emergency Room hospital care or hospital discharge planning
Working Conditions: - Work completed in acute hospital and/or sub-acute and/or Inpatient Rehabilitation setting
- Driving up to one hour per day
Competencies for High Performers: - Participation in departmental projects assigned by Director or Manager
- Certification in Case Management (CCM) or equivalent Professional Certification (ACM)
- Metric measures of success: Observation rate discharge, Rate of engagement with patients high risk patients, improved readmission rate of high risk patients and engagement of PCP HFU rate, daily productivity 10-11 patients per day OBs note
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $35 to $63 per hour based on full-time employment. We comply with all minimum wage laws as applicable.
