Case Manager II, Outpatient

Sutter Health•Novato, CA

1d•$87 - $114

About The Position

We are so glad you are interested in joining Sutter Health! Organization: NCH-Novato Community Hospital Position Overview: Conducts preauthorization, concurrent, and retrospective utilization management review using the department’s accepted criteria for ambulatory, acute, and post-acute patients to confirm medical necessity is met and at the appropriate level of care. Coordinates the utilization management, resource management, discharge planning, post-acute care referrals and care facilitation. Strives to promote patient wellness, improved care outcomes, and efficient utilization of health services among a patient population with complex health needs. Job Description: These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development). Job Description modifications for union represented position are subject to CBA guidelines.

Requirements

Associate Degree in Nursing
Graduate of an accredited school of nursing
RN-Registered Nurse of California
2 years recent relevant experience
A broad knowledge base of health care delivery and case management within a managed care environment.
Comprehensive knowledge of Utilization Review, levels of care, and observation status.
Working knowledge of laws, regulations and professional standards affecting case management practice in an integrated delivery system: including but not limited to: Centers for Medicare and Medicaid Services (GR) Grouper (CMS), Department of Managed Health Care, National Committee for Quality Assurance (NCQA).
A broad knowledge base of outpatient, acute, and post-acute levels of care and associated regulatory compliance requirements.
Must be able to effectively communicate with and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners.
Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.
Demonstrates commitment to service excellence in all patients, family, and employee interactions and in performing all job responsibilities.
Functions in a manner to promote quality patient care and assure a positive patient experience.
Verbal and written communication skills.
Interpersonal communication and negotiation skills.
Must have time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
Intermediate computer skills.
Ability to promote teamwork and to effectively function in teams.
Ability to interact effectively with key internal and external constituents using collaboration, and customer service skills that promote excellence in the patient experience.

Nice To Haves

CCM - Certified Case Manager (certification may be required by entity and time to acquire within 2 years of hire)

Responsibilities

Provides inpatient and ambulatory referral review - manages prior authorizations and retrospective referrals as documented in Utilization Management (UM) Operations Policies and Procedures.
Process referrals based on application of criteria (such as Medicare, MCG, InterQual, health plan, Sutter Health, etc.). Collaborate with UM Medical Directors routinely regarding referrals and all cases not meeting criteria.
Ensure appropriate authorization and denial letters are issued. Work collaboratively with UM staff to handle daily work.
Document all referral activities thoroughly in computer system documentation area (i.e. EPIC, Midas).
Conducts preauthorization, concurrent, and retrospective review using accepted criteria (i.e. Medicare, MCG, InterQual, etc.) for acute hospitalized and post-acute patients to ensure medical necessity for inpatient days and appropriateness of level of care. During acute hospitalization and post acute facility stays, consults with facility care team to develop goals to enhance functional status, identify discharge planning needs and provide continuity of care using community resources.
For cases not meeting criteria, the case manager documents applicable guideline, rationale, and routes to the UM Medical Director for further review.
Issues & documents facility or regulatory letters as applicable (i.e. Authorizations, Notice of Medicare Non-Coverage, Detailed Explanation of Non-Coverage, Refusal to Transfer, Notice of Non-Coverage Termination of Services letters, etc.).
Works collaboratively with members of a patient’s care team (i.e. physician, nurses, rehab team, social worker, facility case managers, etc.). This includes active participation in interdisciplinary meetings in acute or post-acute settings.
Provide authorizations to contracted facilities in accordance with health plan contracts or facilitate obtaining letter of agreements as needed.
Facilitates repatriation of out-of-network patients and escalates as needed when there is a delay in repatriation.
Identify and refer patients to Sutter’s Value Based Case Management team as appropriate (includes complex case management, transitions of care, disease or population case management, etc.).
Comply with health plan and regulatory prior authorization turnaround timeframes.
Comprehension of health plan contracts (i.e. scope of authorization, division of financial responsibility, carve-outs, risk and shared risk arrangements, etc.).
Actively participates in interviews and recommends selected applicants for hire.
Serves as a resource for peers.
Identifies new system, processes, protocols and/or methods to improve practices.
Actively contributes to the creation of cost-effective practices that ensure the best patient experience, effective resource utilization and enhance outcomes.
Accurately prepares handoff report as necessary (i.e. vacations or time-off)
Active awareness of Sutter Organization, affiliate, and department communications and strategies from various communication sources
Uses effective interpersonal and communication skills to promote customer service with internal and external customers
Develops and maintains positive, productive, professional relationships with the healthcare team and representatives of the community agencies.
Relates with tact and respect to all customers (some of whom may be exhibiting varying levels of distress) with diverse cultural and socioeconomic backgrounds without personal judgment.
Functionally supervises and positively contributes to the team’s decision-making process.
Willingly provides and accepts direct, constructive feedback to and from colleagues and the leadership team. Actively uses effective communication skills with colleagues to resolve issues in a timely manner.