Case Manager I-BU:RN ACM / Spectrum Corporate Kearny Mesa Office / Full Time / Days
Company: SHARP HEALTHCARE
Location: Riverside
Posted on: May 11, 2022
Job Description:
What You Will DoThe RN CM I assesses, develops, implements,
coordinates and monitors a comprehensive plan of care for each
patient/family in collaboration with the physician, social worker
and all members of the interdisciplinary team in the inpatient and
emergency department patient care areas. This position requires the
ability to combine clinical/quality considerations with
regulatory/financial/utilization review demands to assure patients
are receiving care in the appropriate setting and level of care.
The position creates a balance between individual clinical needs
with the efficient and cost effective utilization of resources
while promoting quality outcomes.Required Qualifications
- 3 Years Recent acute care nursing experience or case management
experience
- California Registered Nurse (RN) - CA Board of Registered
Nursing -REQUIREDPreferred Qualifications
- Bachelor's Degree in Nursing
- Certified Case Manager (CCM) - Commission for Case Manager
Certification -PREFERREDEssential Functions
- Professional developmentThe RN CM I will:Actively participates
in the performance-planning, competency and individual development
planning process.Maintain current knowledge of case management,
utilization management, and discharge planning, as specified by
Sharp, federal, state, and private insurance guidelines.
- Core principlesThe RN CM I will make timely referrals to ensure
that the patient is receiving the appropriate care, in the
appropriate setting and using the appropriate utilization standards
as set by community and professional standard as adopted by the
medical staff.The RN CM I will assure that the patients from all
age groups proceed efficiently through the course of
hospitalization and beyond through the continuum of care.The RN CM
I will relate and communicate positively, effectively, and
professionally with others; be assertive and consistent in
following and/or enforcing policies; work calmly and respond
courteously when under pressure; lead, supervise, teach,
collaborate and accept direction.The RN CM I performs other duties
as needed.
- Organizational relationshipsThe RN CM I will work closely with
the healthcare team in reaching unit, facility, and system/network
organization goals including reductions in length of stay,
decreasing denials, improvement of care transitions, and reduction
in avoidable readmissions, improved patient experience, and other
quality initiatives.In the emergency departments, the RN CM I will
work collaboratively with other members of the interdisciplinary
team to develop relationships and provide pre admission status
recommendations for admissions as well as implement a
comprehensive, integrated discharge plan from the emergency
department(ED) for patients who are being discharged to a lower
level of care.The RN CM I will recommend and document patient
classification (status and level of care) for all admissions
utilizing established criterion sets.The RN CM I has accountability
for maintaining compliance contractual and regulatory compliance
with medical groups as applicable and the hospital.The RN CM I will
have excellent interpersonal skills demonstrated by the ability to
work effectively with individuals and or teams across
disciplines.
- Care coordination and discharge planningWithin 24 hours of
admission the RN CM I will interview each patient/family for
anticipated needs post hospitalization. The plan and interventions
will be documented in the EMR (e.g., Cerner), and case management
software (e.g., Allscripts Care Management).The RN CM I will
develop and document a plan for the day and plan for the stay with
patient, family, providers, and nursing staff.The RN CM I will be
responsible for leading the daily care coordination
(multidisciplinary) rounds, update the plan, and facilitate
necessary coordination of services.The RN CM I will document and
initiate discharge plan including early referrals and authorization
for LTAC, SNF, Rehab, homecare, DME and infusion services.The RN CM
I will prepare patient/family for discharge. Document expected
discharge date per protocol and arrange discharge pick up
appointment with family or significant other.In collaboration with
SW partner, the RN CM I will follow standards for routine
patient/family conference.The RN CM I will ensure effective and
safe patient handovers to next level of care; work closely with
ambulatory care manager (ACM) at the system level, in clinics, with
SCMG and other complex care Case Managers as appropriate, and
homecare and sub-acute liaisons.The RN CM I will support the
nursing Model of Care by working closely with nursing managers and
staff to achieve Patient and Family Centered Care goals: respect
and dignity, information sharing, participation and
collaboration.The RN CM I will facilitate increased volume of cases
discharged early in the day to improve capacity management.The RN
CM I will collect and document avoidable day's information in
appropriate case management software, e.g., Allscripts Care
Management.The RN CM I will participate in venues to reduce
barriers to discharge.The RN CM I Collaborates with Clinical
Resource Coordinators (CRC's/clinical assistants) to assure
appropriate referrals for care and services are directed to
appropriate network providers, and obtains prior authorization for
in network and out of network services as appropriate.The RN CM I
provides timely delivery of regulatory and mandated patient
communications and correspondence.The RN CM I oversees preparation,
delivery and documentation of non-coverage letters.The RN CM I
identifies and escalates potential quality variances to management
and document per guidelines.The RN CM I interviews all patients
with an admission within 30 days to determine what went wrong in
the discharge. He/she documents as appropriate in Cerner and
Allscripts Care Management and provides information to the
department head as indicated.
- Utilization review and utilization managementThe RN CM I
will:Conduct initial review at POE or within 24 hours of admission
utilizing appropriate care guidelines software. Document findings
in CM software, e.g., Allscripts Care Management.Identify
anticipated LOS and document in Allscripts Care Management,
communicate to healthcare team.Conduct daily concurrent reviews per
protocol/policy and payer request.Utilize appropriate care
guideline software to identify the correct patient status and level
of care.Work with attending provider to assure correct status, if
status and order does not match; works with provider to resolve
conflict and document interventions in Allscripts Care
Management.Assure correct documentation is present for 2MN
benchmark and presumption.Assure Medicare Inpatient to observation
status changes follow Condition Code 44 requirements.Actively work
observation patient list assuring transitions to next level of
Care.Communicates as indicated with third party payers to obtain
necessary authorization for reimbursement of services. Obtain
approved days/LOS from provider and communicates this to the care
team.Refer defined cases for medical secondary review and share
findings with providers.Provide advice to Revenue Cycle/HIM
regarding RAC decision to appeal, denials, input into appeals,
share findings with providers.Review all cases with readmission
within 30 days; report findings in Care Management software such as
Allscripts Care Management.Identify opportunities for cost
reduction and participate in appropriate utilization management
venues.Escalate and refers cases for consultation with Physician
Advisor or Medical Director as appropriate.Oversee preparation,
delivery and documentation of non-coverage letters.Knowledge,
Skills, and Abilities
- PC, data management and analysis skills required, (experience
with InterQual, and or MCG and Allscripts Care Management an
Asset).
- Excellent interpersonal skills, as demonstrated by the ability
to work effectively with individuals and or teams, and across
disciplines.
- Excellent communication and negotiation skills as demonstrated
in oral and written forms.
- Ability to work in a collaborative partnership model with
Social Workers and other members of the interdisciplinary team,
both internal and external. Organizational and time management
skills, as evidence by capacity to prioritize multiple tasks.Sharp
HealthCare is an equal opportunity/affirmative action employer. All
qualified applicants will receive consideration for employment
without regard to race, religion, color, national origin, gender,
gender identity, sexual orientation, age, status as a protected
veteran, among other things, or status as a qualified individual
with disability or any other protected classBachelor's Degree in
Nursing; California Registered Nurse (RN) - CA Board of Registered
Nursing; Certified Case Manager (CCM) - Commission for Case Manager
Certification
Keywords: SHARP HEALTHCARE, Riverside , Case Manager I-BU:RN ACM / Spectrum Corporate Kearny Mesa Office / Full Time / Days, Executive , Riverside, California
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