Transitional Case Manager RN

Managed Care Systems LLC  •  Scotts Valley, CA

Less than 5 years experience  •  Managed Care & Health Insurance

$80K - $100K
Posted on 10/12/17
Managed Care Systems LLC
Scotts Valley, CA
Less than 5 years experience
Managed Care & Health Insurance
$80K - $100K
Posted on 10/12/17



Under general direction of the Medical Director, provide utilization management and transitional care support in the inpatient and/or outpatient facility setting, collaboratively assessing, planning, facilitating and evaluating timely coordination of quality, and cost-effective care across the continuum.



  •   Must be a graduate of an accredited nursing program and maintain current unrestricted California license as a Registered Nurse.
  •  Three years Utilization Management R.N. experience in a Medical Group, Health Plan, Acute Care Hospital or equivalent is required. Quality Improvement experience is preferred.
  •  Able to deal with complex and variable mental applications with numerous interruptions.
  •  Working knowledge and proficient in computer applications such as Microsoft Word and the Internet.
  •  Working knowledge of Interqual Criteria for Inpatient stays.
  •  Experience and knowledge in discharge planning preferred.
  •  Effective verbal and written communication skills with internal and external customers, i.e., healthplans, case managers, home care agencies, physicians, nursing staff and other ancillary personnel.
  •  Knowledge regarding managed care insurances, governmental health programs, HMO's and their impact on hospital and post hospital care reimbursement.


Hospital Utilization Management


  • Working with PMG Hospitalists and PMG providers, perform admission and/or continued stay reviews on all inpatients evaluating appropriateness of the setting based on InterQual Intensity of Service and Severity of Illness (IS/SI) criteria.
  • Contact attending physician and/or hospitalist if IS/SI criteria is not present on admission or continued stay reviews.
  • Promote and assist PMG Physicians and hospital staff to assess and support the most efficient health care decisions.
  • Promote and assist PMG Physicians and hospital staff to determine and transition to the appropriate next step level of care for patients in the Emergency Department (ED).
  • Promote and assist PMG Physicians and hospital staff to formulate a realistic discharge plan based on patient’s need to provide for continuity of care post hospitalization.
  • Work with Hospital Nurse Case Managers to support proactive discharge planning for hospitalized patients using contracted providers and community resources to facilitate coordinated discharge. 
  • Work with PMG Primary Care Providers to support use and understanding of community and family resources and to coordinate patient care post-discharge from the ED or the hospital.

Transitions of Care

·        Triage members based on identified care transition protocol.

·        Screen members for care transition services prior to elective admissions.

·        Visit member while in hospital as needed.

·        Coordinate care with Hospitalists, Specialists, SNFists, and home health.

·        Coordinate care team meetings with member, family / caregivers and physicians, as needed.

·        Provide oversight of inter-facility transfers (SNFs, ARU, etc.)

·        Follow members for up to 60-days; minimum of three telephonic contacts (days 2, 7, 14, 30, 45 & 60).

·        Provide medication reconciliation.

·        Review health plan pharmacy data for enrolled members.

·        Assure post-acute physician follow-up visit within 24 - 72 hours for high risk members.

·        Emphasize to PCPs/PAs/NPs and other office staff the importance of timely follow-up.

·        Coordinate care with PCP.

·        Implement PCP/specialist driven care plan.

·        Emphasize medication reconciliation, symptom management, and care coordination.

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