Case Manager HRC-148

Job Summary:

Case Management/Utilization Review RN is responsible for intake and providing case management services for the medically and/or socially complex patients. Responsible to develop plans for patient and family self-care competence including motivational assessment assessing for desired level of involvement and coaching for adherence to care plan; provide nursing assessment create and monitor patient/family care plans including end of life planning. The Case Management/ Utilization Review RN promotes knowledge of this program throughout Hazel Hawkins Memorial Hospital additional hospitals and programs where medically homed patients live and receive addition s/he is responsible to create and sustain partnerships with community resources and support agencies. The Case Management / Utilization Review RN has well-developed knowledge and skills in areas of utilization review (UR) medical necessity and patient status determination. This individual supports the UR program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for performing a variety of concurrent and retrospective UR-related reviews and functions and for ensuring that appropriate data is tracked evaluated and reported. This individual monitors the effectiveness/outcomes of the UR program identifying and applying appropriate metrics evaluating the data reporting results to various audiences and designing and implementing process improvement projects as needed. This individual maintains current and accurate knowledge regarding commercial and government payers and Joint Commission regulations/guidelines/criteria related to UR

Duties/Responsibilities:

• Responsible for utilization management
• Identifies and prioritizes case management and utilization review needs of patients
• Conducts utilization review for medical necessity (appropriateness) prospectively concurrently and retrospectively
• Determines the medical necessity of admission continued stay treatments tests and procedures
• Documents and addresses service delays
• Uses current utilization guidelines
• Minimizes discharge delays and the unnecessary use of acute care resources.
• Tracks trends and displays utilization data and analyzes utilization (resource use) data by drawing conclusions about the data and making recommendations for improvement to Utilization Review Committee.
• Uses measurement and feedback to produce significant improvements in resource use and efficiencies
• Integrates utilization management with the medical staff services (physician profiling for utilization) and the quality improvement program
• Develops and maintains communication and rapport with contract payers and healthcare providers to promote services and to identify ways of best caring for patients
  • Demonstrates patient advocacy skills and knowledge of the Patient Bill of Rights
  • Involves the patient and family in planning care across the continuum
  • Equips patient and family to make informed choices about continuing care options
  • Serves as the organizations expert at coordinating care. Uses facilitates and role models as hospital-wide case management approach to reduce fragmentation and duplication in care delivery
  • Provides coaching and resources to staff to use case management strategies including clinical pathways documentation of outcome and interventions for variances assisting patients with self-care skills health promotion and prevention.
  • Accountable for the provision of CM services to specific patients upon referral by physicians or nurses
  • Case manages high-risk complex unpredictable patient conditions
  • Discusses CM and UR issues with physicians nurses and other providers on a daily basis.
  • Participates in the design and revision of critical pathways using an interdisciplinary process and evidence based clinical practice guidelines.
  • Establishes and maintains standards for appropriate and timely discharge planning
  • Assures the early identification of post-hospitalization needs (availability of resources and support systems) starting with pre-admission discharge planning
  • Collaborates with the interdisciplinary care team (at daily meetings) to provide seamless care delivery through discharge planning and facilitates communication among all disciplines involved in the provision of care
  • Communicates with third party payers to secure authorization for care and to coordinate post-hospitalization care needs (i.e. transportation equipment supplies placement or other community resources).
  • Interfaces with local agencies to arrange needed patient services.
  • Facilitates inter-facility transports assuring compliance with COBRA regulations
  • Obtains all pertinent health financial and social data necessary to complete the referral

Required Skills/Abilities:

• Knowledge of county resources
• Good communication skills both verbal and written
• Knowledgeable regarding managed care environment and other payor sources

Education and Experience:

Graduated from an accredited school of nursing

Current R.N. license to practice in California

Minimum of two years of utilization review discharge planning or equivalent experience required

MSN preferred

• Previous leadership/management experience preferred