Case Manager, Utilization RN - PRN

About the role

• May be entitled to translation/bilingual, shift or other wage premiums as governed by the applicable collective bargaining agreement.

Job Summary

Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays either telephonically or on-site. Makes recommendations to the physicians for bed day management andalternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization, skilled nursing or post-acute benefits.

Interacts with the family, patient and other disciplines (including but not limited to MDs, RNs, Social Workers) to coordinate a safe and acceptable discharge plan, as needed. Functions as an indirect caregiver, patient advocate and manages patients in the most cost-effective way without compromising quality.

Essential Responsibilities

• Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with peers, multidisciplinary teams and multitask and in a fast pace environment.
• Plans, develops, assesses and evaluates care provided to members. Reviews, monitors, valuates and authorizes the medical necessity of inpatient, skilled, or sub-acute admissions demonstrating knowledge and experience in the application of clinical criteria to determine medical necessity for inpatient hospitalization, skilled nursing or post-acute venues of care. Performs all utilization review activities according to Resource Stewardship department policies and procedures.
• Participates in clinical review round activities preparing case presentation and documentation. Notifies facilities and others of review decisions timely after applying approved criteria and/or established guidelines, including adverse determinations, as recommended by the Medical Director. Identifies high-risk/high utilizers of services to monitor their intensity and level of services and reports potential high dollar cases appropriately per policies and procedures. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs in collaboration with discharge planners and care managers, as necessary. Documents all necessary information timely into medical management systems or pursuant to appropriate policies and procedures ensuring complete and accurate data. Participates in the Bed Huddles and/or telephonic concurrent review calls and carries out recommendations congruent with the patients needs.
• Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies. Refers patients to community resources to meet post hospital needs through discharge planning and care management. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOLPerforms other job related responsibilities as may be required from time to time.
• Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.
• The union and the company are currently investigating the qualifications for this position under the bargaining unit. If it is determined that the qualifications are different than as described, appropriate action will be taken.