Case Manager I - Transition Planner - Sharp Memorial Hospital - FT - Day Shift

Sharp Healthplan•San Diego, CA

47d•$57 - $84•Onsite

About The Position

The RN CM I assesses, develops, implements, coordinates and monitors a comprehensive plan of care for each patient/family in collaboration with the physician, social worker and all members of the interdisciplinary team in the inpatient and emergency department patient care areas. This position requires the ability to combine clinical/quality considerations with regulatory/financial/utilization review demands to assure patients are receiving care in the appropriate setting and level of care. The position creates a balance between individual clinical needs with the efficient and cost-effective utilization of resources while promoting quality outcomes. This position requires critical thinking and advanced problem-solving and time management skills.

Requirements

2 Years Recent acute care nursing experience, case management experience or equivalent experience in the healthcare setting.
California Registered Nurse (RN) - CA Board of Registered Nursing

Nice To Haves

Bachelor's Degree in Nursing or equivalent degree.
Master's Degree
Certified Case Manager (CCM) - Commission for Case Manager Certification
Accredited Case Manager (ACM) - American Case Management Association (ACMA)
PC, data management and analysis skills required (experience with MCG an asset).
Excellent interpersonal skills, as demonstrated by the ability to work effectively with individuals and or teams, and across disciplines.
Excellent communication and negotiation skills as demonstrated in oral and written forms.
Ability to work in a collaborative partnership model with Social Workers and other members of the interdisciplinary team, both internal and external.
Organizational and time management skills, as evidence by capacity to prioritize multiple tasks.

Responsibilities

Actively participates in the performance-planning, competency and individual development planning process.
Maintain current knowledge of case management, utilization management, and discharge planning, as specified by Sharp, federal, state, and private insurance guidelines.
Make timely referrals to ensure that the patient is receiving the appropriate care, in the appropriate setting and using the appropriate utilization standards as set by community and professional standard as adopted by the medical staff.
Assure that the patients from all age groups proceed efficiently through the course of hospitalization and beyond through the continuum of care.
Relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following and/or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, collaborate and accept direction.
Perform other duties as needed.
Work closely with the healthcare team in reaching unit, facility, and system/network organization goals including reductions in length of stay, decreasing denials, improvement of care transitions, and reduction in avoidable readmissions, improved patient experience, and other quality initiatives.
Work collaboratively with other members of the interdisciplinary team to develop relationships and provide preadmission status recommendations for admissions as well as implement a comprehensive, integrated discharge plan from the emergency department(ED) for patients who are being discharged to a lower level of care.
Recommend and document patient classification (status and level of care) for all admissions utilizing established criterion sets.
Maintain compliance contractual and regulatory compliance with medical groups as applicable and the hospital.
Have excellent interpersonal skills demonstrated by the ability to work effectively with individuals and or teams across disciplines.
Within 24 hours of admission interview/assess each patient/family for anticipated needs post hospitalization.
Ensure patient choice is obtained and documented in accordance with all state and federal regulatory requirements.
Document the plan and interventions in the electronic medical record (EMR), and case management software.
Develop and document a plan for the day and plan for the stay with patient, family, providers, and nursing staff.
Be responsible for leading the daily care coordination (multidisciplinary) rounds, update the plan, and facilitate necessary coordination of services.
Document and initiate discharge plan including early referrals and authorization for LTAC, SNF, Rehab, homecare, DME and infusion services.
Prepare patient/family for discharge. Document expected discharge date per protocol and arrange discharge pick up appointment with family or significant other.
Follow standards for routine patient/family conference in collaboration with SW partner.
Ensure effective and safe patient handovers to next level of care; work closely with ambulatory care manager (ACM) at the system level, in clinics, with SCMG and other complex care Case Managers as appropriate, and homecare and sub-acute liaisons.
Support the nursing Model of Care by working closely with nursing managers and staff to achieve Patient and Family Centered Care goals: respect and dignity, information sharing, participation and collaboration.
Facilitate increased volume of cases discharged early in the day to improve capacity management.
Collect and document avoidable day's information in appropriate care management software.
Participate in venues to reduce barriers to discharge.
Collaborates with Clinical Resource Coordinators (CRC's/clinical assistants) to assure appropriate referrals for care and services are directed to appropriate network providers, and obtains prior authorization for in network and out of network services as appropriate.
Provide timely delivery of regulatory and mandated patient communications and correspondence.
Oversee preparation, delivery and documentation of non-coverage letters.
Identify and escalate potential quality variances to management and document per guidelines.
Interview all patients with an admission within 30 days to determine what went wrong in the discharge.
Document as appropriate in the electronic medical record and provides information to the department head as indicated.
Conduct initial review at POE or within 24 hours of admission utilizing appropriate evidenced based care guidelines software. Document findings in ICM software (EMR).
Identify anticipated LOS and document as per departmental process.
Conduct daily concurrent reviews per protocol/policy and payer request.
Utilize appropriate care guideline software to identify the correct patient status and level of care.
Work with attending provider to assure correct status, if status and order does not match; works with provider to resolve conflict and document interventions in the EMR.
Assure correct documentation is present for 2MN benchmark and presumption.
Assure Medicare Inpatient to observation status changes follow Condition Code 44 requirements.
Actively works observation patient list assuring transitions to next level of Care.
Communicates as indicated with third party payers to obtain necessary authorization for reimbursement of services. Obtain approved days/LOS from provider and communicates this to the care team.
Refer defined cases for medical secondary review and share findings with providers.
Provide advice to Revenue Cycle/HIM regarding RAC decision to appeal, denials, input into appeals, share findings with providers.
Review all cases with readmission within 30 days; report findings in the EMR and in accordance with the departmental policy.
Identify opportunities for cost reduction and participate in appropriate utilization management venues.
Escalate and refers cases for consultation with Physician Advisor or Medical Director as appropriate.
Oversee preparation, delivery and documentation of non-coverage letters.