The RN Case Manager is responsible for performing a high level clinical assessment and reassessment of acute care Inpatients for the purpose of performing utilization review, resource management and safe discharge planning. The RN Case Manager prioritizes, plans, organizes, and implements timeliness of care. Collaborates with the interdisciplinary healthcare team to promote and coordinate the delivery of safe and cost-effective patient care, transition of care and discharge planning. The RN Case Manager advocates for patient self-determination and choice. Practices clinical competence in evaluations and planning with awareness and respect for patient and family diversity. Monitors and coordinates resource utilization throughout the continuum of care and evaluates timeliness of services. Performs admission, continued stay and discharge review utilizing medical staff-approved decision support criteria. Ensures case management documentation in the medical record is clear and complete.Foothill Regional Medical Center is a fully accredited acute care hospital, licensed for 177 beds-120 beds for general acute care, 15 intensive care beds and 42 pediatric sub-acute beds. Our pediatric sub-acute unit, just one of six in California, serves patients from throughout the state. We care for patients up to 21 years of age who need long-term sub-acute care including ventilator care and nutritional support.Required Qualifications:
One year of case management experience
Current Licensure as a Registered Nurse in the State of California
Computer/EMR Proficiency and Literacy
Knowledge of CMS, Medicare, Medi-Cal and Managed Care reimbursement
Familiarity of Joint Commission, CMS, CDPH requirements
Excellent written and verbal communication skills in English
Ability to establish and maintain effective working relationships across the organization
Ability to facilitate and lead interdisciplinary rounds
Preferred Qualifications:
Bachelor of Science in Nursing
Certified Case Manager (CCM)
Familiarity with AllScripts Care Management
Proficiency with Milliman Care Guidelines or Interqual
Bilingual skills to communicate effectively with patients and families
Pay Rate: Min - $46.10 | Max - $63.40
Collaborates as needed with the patient and family to optimize client outcomes. May include work with community, local and state resources, primary care provider, and members of the health care team, payer, and other relevant health care stakeholders to facilitate appropriate patient transfers, discharges and transitions of care. Identifies timely and effective alternative lower level of care settings for patient care in accordance with the patient's medical necessity, stability, the patients' preferences and health plan benefits. Identifies timely post-hospital needs and arranges for services as appropriate. Provides patient and family appropriate resources and/or referrals. Makes timely and appropriate referrals to, and seeks consultation with others when needed, the patient-centered provision of services; such as Social Services (i.e., Durable Power of Attorney).
Reviews medical necessity utilizing medical staff-approved evidence-based decision support criteria. to determine appropriate level of care and length of stay. Ensures utilization review is completed and documented concurrently, and provided to the patient's payer as required. Ensures timely escalation of unresolved care coordination issues to the appropriate level. Enters delays in service and avoidable days regarding exceeded payer LOS variances. Communicates denials and physician related utilization management practices to immediate supervisor same day as identified.
Collaborates with patients/caregivers to set goals consistent with physician treatment plans, and patient resources and choices. Collaborates with the multidisciplinary team for timely discharge planning assessments and reassessments and documents concurrently in the patient's medical record in compliance with hospital policy and all regulatory agencies. Provides appropriate instructions to discharge care coordinators as needed.
Acts as an effective liaison to medical staff to ensure continuity and congruity of hospital services in accordance with the patient's plan of care.
Participates in patient and family meetings; respecting and promoting patient choice and documents informed decision making. Utilizes knowledge of psycho-social and physical factors that affect functional status on discharge.
Contributes requested data for the Utilization Management Committee.
Collaborates as needed with the patient and family to optimize client outcomes. May include work with community, local and state resources, primary care provider, and members of the health care team, payer, and other relevant health care stakeholders to facilitate appropriate patient transfers, discharges and transitions of care. Identifies timely and effective alternative lower level of care settings for patient care in accordance with the patient's medical necessity, stability, the patients' preferences and health plan benefits. Identifies timely post-hospital needs and arranges for services as appropriate. Provides patient and family appropriate resources and/or referrals. Makes timely and appropriate referrals to, and seeks consultation with others when needed, the patient-centered provision of services; such as Social Services (i.e., Durable Power of Attorney).
Reviews medical necessity utilizing medical staff-approved evidence-based decision support criteria. to determine appropriate level of care and length of stay. Ensures utilization review is completed and documented concurrently, and provided to the patient's payer as required. Ensures timely escalation of unresolved care coordination issues to the appropriate level. Enters delays in service and avoidable days regarding exceeded payer LOS variances. Communicates denials and physician related utilization management practices to immediate supervisor same day as identified.
Collaborates with patients/caregivers to set goals consistent with physician treatment plans, and patient resources and choices. Collaborates with the multidisciplinary team for timely discharge planning assessments and reassessments and documents concurrently in the patient's medical record in compliance with hospital policy and all regulatory agencies. Provides appropriate instructions to discharge care coordinators as needed.
Acts as an effective liaison to medical staff to ensure continuity and congruity of hospital services in accordance with the patient's plan of care.
Participates in patient and family meetings; respecting and promoting patient choice and documents informed decision making. Utilizes knowledge of psycho-social and physical factors that affect functional status on discharge.
Contributes requested data for the Utilization Management Committee.
