POSITION SUMMARY
The Case Manager provides case management services to those members identified as needing assistance in navigation of the healthcare system, linkage to both Physicians and/or Health Plan providers and community resources. CM can also be used when a member poses possible financial risk due to: a) unnecessary emergency department (ED) usage; b) hospital readmissions; and, c) other over or under use of appropriate resources to manage the members medical or behavioral healthcare needs. The Case Manager will perform his/her duties through use of skilled interventions, {objective and subjective criteria}, clinical best practice knowledge, critical thinking and collaboration with the member/family, physician and multidisciplinary treatment team. The primary goal of CM is to assist and keep the pace of care moving to achieve quality outcomes once the member’s individualized care plan is developed and implemented. The Case Manager makes use of positive partnerships with the member/family, nursing, physicians and other key disciplines in the multidisciplinary care team all of which are needed to assist Physicians in successful Health Plan or regulatory audit results while also ensuring financial goals are reached by ensuring the member is at the right level of care throughout the course of their illness or injury and over and under use of healthcare benefits or community resources are eliminated.
SKILLS
- Excellent interpersonal communication and negotiation skills with multidisciplines and peers both internally and externally.
- Excellent written and organizational skills required.
- Knowledge about Best Practice, clinical trajectories, recovery patterns
- Strong analytic and data management and computer skills
- Ability to follow the chain of command, knowledge of medical terminology and current third-party payer reimbursement methodologies, self-motivated and results oriented.
- Ability to work independently without direct supervision over time, decisions, or standards
- Must be able to demonstrate sound decision making and prioritization skills, managing multiple priorities for assigned caseload
- Basic knowledge of health care law and regulations related to acute care and the immediate post-acute continuum
EXPERIENCE
- Maintains an active California LVN or RN license
- Minimum of 2 years medical surgical acute hospital setting practice
- 1-2 years of Case Management experience preferred
- Proficiency with main-frame and personal computers
DUTIES AND RESPONSIBILITIES
- Safeguards and preserves the confidentiality of patient’s protected health information in accordance with State and Federal (HIPAA) regulatory requirements, hospital and departmental policies.
- Ensures a safe patient environment and adherence to safety practices per policy.
- Maintains specific competencies.
- The CM is responsible for following patients from intake until case closure, working within the timeframes as outlined contractually with the Health Plans or state or federal agency for CM activities, the internal Physicians staff, physicians, patients/families, the hospital and/or contracted Health Plans and any other third-party payers to create and maintain quality and fiscal responsibility.
- Performs an initial CM assessment of all newly assigned members to their caseload, developing and implementing an individualized Care Plan jointly with the member or their surrogate decision maker.
- Performs case activity to keep the plan of care moving towards established goals and as needed identifying any barriers to reaching goals and case closure.
- Documents all discussions and case actions in the member’s assigned CM chart.
- Provides support to the multidisciplinary care team by communicating both verbally and through accurate and complete documentation any pertinent payer findings and requirements as determined necessary to facilitate reimbursement by payer as well as continuity for patient care.
- Provides clinical expertise and assists with the clinical facilitation, development and implementation of multidisciplinary case management plans for all patients as well as those who visit the ED frequently and/or are admitted.
- Utilizes critical thinking in all interactions in order to identify variances/problems, applying sound decision-making skills as case management, utilization review and discharge planning activities are performed.
- Displays excellent assessment experience and skills by utilizing evidence-based practice, nursing expertise, critical thinking, knowledge, and skilled intervention in order to complete comprehensive assessments and facilitate an appropriate utilization review and discharge plan for all assigned cases.
- Acts as a resource/advisor to physicians at a minimum of case management, key processes associated with CM activity and how their input into the care plan is critical and how referrals can be generated.
- Develops positive, pro-active working relationships with assigned physicians by providing them with feedback regarding their patients, both clinically and financially.
- Develops a network of information regarding community resources and levels of care which allows the CM to be a resource/advisor to physicians about community resources and post-acute levels of care which will meet the patient’s ongoing post-acute medical needs and allow a safe discharge.
- Ensures all CM letters and correspondence or educational materials are issued as per guidelines or any state or federal mandates for dissemination of such to member or providers.
- Coordinates with the UM staff on any authorizations or letters of agreement or other documents that might be needed in the course of arranging for linkage of a member to needed care or services either at discharge or for implementation of Care Plan needed services.
- Works in collaboration or assists in gathering and analyzing data, preparing reports, assisting in any Health Plan or state or federal audits, making recommendations, and collaborating with other team members to ensure proper documentation and resource utilization and case activity occurred as per any contractual mandates and avoid any corrective action plans.
- Works in collaboration with the CM Director/manager and all staff to decrease patient readmissions and identify quality and risk issues and improve patient satisfaction.
- Participates in continuing education pertaining to any CMS regulations or other regulatory or payer requires, as well as any other training deemed appropriate by CM Department Director/manager.
- Demonstrates positive customer service.
- Utilizes positive guest relations, support care centers and hospital administration. Attends staff and other appropriate meetings.
- Performs other duties as assigned, if within scope of practice.
Work schedule is 3 week days plus Saturday/Sunday.
Job Type: Full-time
Pay: From $32.00 per hour
Expected hours: 40 per week
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid sick time
- Paid time off
- Vision insurance
Work setting:
Work Location: In person