Oversees the higher level of care cases and the process and the management of our inpatient transplant cases. Will be responsible for answering any questions the inpatient nurses might have during their shift with the direction of the Lead La Care Shared Risk Nurse, and Medical Directors. Provides overall coordination in the delivery of medical services and discharge planning for a specified patient population.
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Maintains updated list of HLOC facilities for Health plans / capped hospitals.
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Maintains workflow for HLOC, Transplant, COC workflow process for the team to follow
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Provides cheat sheet for go to specialists for the team to easily access.
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Maintains list of hospitals that do special procedures, not limited to, EUS, open MRI, TAVR, and etc.
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Oversees HLOC Cases and Inpatient Transplant cases
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Ensures that communication regarding HLOC cases and transplant cases is clear and easy to understand, and current updates are documented
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Ensures that authorizations are obtained from the individual health plans when needed for members being moved to either tertiary centers or for transplant purposes
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Ensures that condition codes are added for members that fall into the category of transplants
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Ensures that LOA’s are submitted and completed for non-contracted providers and facilities when deemed necessary
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Assists Health Plan Medical Director as needed i.e., information on who are the contracted providers for the IPA, key contacts when bringing a member from OOA/OON into network
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Maintains COE for organ transplants and assists in obtaining TAR
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Attends the HLOC inpatient meeting to go over HLOC / Transplant cases and reports to the Medical Directors.
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Refers potential readmissions to Outpatient High Risk Case Management (SPD, SNP, CMC) or Readmission Teammates (non-SPD, non-SNP, non-CMC) for follow-up post discharge. Refers any potential quality of care issues (PQI) identified to the QI Department for review of QI cases.
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Provides coverage as needed.
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Current RN or LVN licensure; Preferred: BSN level of education.
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Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review/quality assurance, use of Milliman or other clinical decision support criteria, discharge planning, and reimbursement structures (i.e., Government and non-governmental payers).
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Ability to read, analyze and comprehend complex clinical data and its application to level of care criteria and discharge options; strong, broad-based clinical knowledge and understanding of pathology/physiology of disease processes; excellent critical thinking skills; assertive personality traits to facilitate ongoing physician communication; organize, prioritize, and manage time efficiently.
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Ability to pursue issues proactively with forward thinking.
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Ability to identify improvement opportunities and set realistic goals for the TMs to achieve.
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Ability to communicate effectively with direct TM’s both in meetings and written communication.
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Ability to communicate effectively with a wide range of hospital personnel, physicians, patients/family members within various socioeconomic groups and representatives of varied outside agencies.
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Computer literacy and familiarity with the operation of basic office equipment.