Access Case Manager

PIONEERS MEMORIAL HEALTHCARE DISTRICT • Brawley, CA

8d • $68,280 - $93,885

About The Position

The Access Case Manager evaluates the medical necessity for admission status. Assesses for transition planning, and other measures for safe discharge to appropriate level of care. Coordinates post-hospital care when necessary.

Requirements

• Organization, analytical, writing, and interpersonal skills.
• Dependable, self-directed, and pleasant.
• Critical thinking, problem solving and deductive reasoning skills.
• Recent hospital experience preferably ICU, CCU, or strong minimum 3 years Med/Surg. Experience.
• Knowledge of Pathophysiology and Disease Process.
• Knowledge of Medicare, Medicaid, and Managed Care Health Plans.
• Associate degree Nursing required.
• Current American Heart Association BLS required.

Nice To Haves

• Experience in Hospital Case Management preferred.
• Bachelor’s degree in nursing preferred
• ACMA, CCM Preferred.

Responsibilities

• Initial patient screening: Identifies high risk patients through rounding and referrals from ED and admitting physicians, surgical services, nurses, hospitalists, ED patients and families, and other mechanisms as appropriate. Uses ED tracking system, medical record, and demographic information to identify patients needing CM intervention. Identifies patients with frequent ED visits. Identifies patients returning to ED within 2-3 days. Documents according to policy.
• Utilization review: Screens all patients who meet medical necessity. Works with the admitting physician and admissions to ensure admission to the appropriate status (e.g., inpatient, observation, outpatient in a bed), and level of care (ICU, telemetry, etc.) using InterQual or approved criteria. Educates community-based and ED physicians and staff to understand admission status and appropriate patient placement and other regulatory requirements. Reviews surgical schedules to ensure appropriate status for surgical patients. Reviews all transfers-in for appropriateness of admission and intervenes as necessary. Escalates to physician advisor when unable to resolve issues with the attending physician, according to policy and timeframes established. Preadmission hospital issued notice of non-coverage (HINN) for Medicare patients per physician advisor determination and Medicare guidelines, when medical necessity criteria are not met. Documents according to policy. Case Managers who provide care to Joint Replacement patients will receive 1 hour of ortho/joint replacement specific education yearly.
• Care coordination and patient flow: Initiates the Care Coordination Assessment for select patients. Facilitates communication and information to all stakeholders.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree