Case Manager, RN

AHMC Healthcare•Whittier, CA

1d•$48 - $61

About The Position

Under the general supervision of the Case Management Director, the Case Manager, RN acts as a patient advocate and case manager for hospital clients. This autonomous role coordinates, negotiates, and procures services and resources for complex patients, managing their care to support quality and cost-efficient outcomes. The role identifies opportunities to reduce costs while maintaining the highest quality of care; applies review criteria to determine medical necessity for admission and continued stay; and provides clinical case management, discharge planning, and care coordination to promote cost-effective health care and appropriate resource utilization across the continuum of care. The Case Manager works collaboratively with interdisciplinary staff within and outside the organization and participates in quality improvement and evaluation related to patient care. The position performs initial screening of elective inpatient admissions, coordinates pre-admission screening and education, manages transfer and managed-care admission processes, and supports discharge planning. It also provides clinical guidance and education to admitting staff and physicians, maintains tracking and reporting data, coordinates referrals and transportation when needed, and contributes to departmental and hospital performance improvement. The role requires professional communication, confidentiality, sound judgment, productivity, participation in required education and meetings, and maintenance of applicable licensure and certifications.

Requirements

Current, valid California RN license.
At least 5 years of experience in an acute-care setting.
At least 1 year of discharge-planning experience.
Working knowledge of InterQual IS-SI, Milliman & Robertson Managed Care Guidelines, Erickson Life Skills (Age Competencies), Medicare Part A and Part B, Medi-Cal, NCQA, HEDIS, and other criteria identified by the Quality/Case Management Department.
Working knowledge of Care-M.A.P. development and implementation.
Working knowledge of managed care and capitation.

Nice To Haves

Bachelor of Science in Nursing or a bachelor's degree in Health Care Administration is preferred.

Responsibilities

Screen elective inpatient admissions for level of care, appropriateness of admission, discharge needs, third-party contractual arrangements, and appropriate resource utilization.
Coordinate pre-admission screening and education for identified patient populations.
Coordinate out-of-area transfers.
Document patients admitted directly through Pre-Admissions in the laptop system and forward information to Case Managers, including discharge-planning concerns and the initial discharge-planning screen.
Develop educational programs for pre- and post-operative surgeries, high-risk screening tools, Care-Maps for the Pre-Admit phase of identified populations, and proactive discharge planning.
Coordinate out-of-area and out-of-network managed-care admissions, ensuring criteria and appropriate level of care are met according to InterQual and Milliman & Robertson guidelines.
Select and assign admission types, such as inpatient, 23:59, and SOS.
Interact with admitting physicians and involve the Physician Adviser as needed regarding inappropriate admissions, transfers, or levels of care.
Oversee obtaining Pre-Admit TARs and verify appropriate payer networks among the patient's health-care team.
Provide clinical resources and ongoing education to the admitting department, physicians, physician-office staff, and nursing about Pre-Admission Case Management and Quality/Case Management resources.
Maintain tracking and data statistics as requested for the Case Management Commitment to Quality role.
Follow hospital and department policies and procedures and participate in performance/process improvement activities.
Maintain professional, courteous interactions with patients, families, medical staff, visitors, coworkers, and other departments; contribute to teamwork and positive guest relations.
Prioritize and complete work efficiently, exercise independent judgment, and seek assistance when appropriate.
Maintain accurate and legible documentation, confidentiality, a neat work area, and equipment in accordance with health and safety codes; report safety issues and equipment failures.
Complete annual requirements, safety updates, orientation, mandatory in-service programs, continuing education, and applicable licensure or certification requirements on time; attend staff meetings or review their minutes.
Communicate clearly and professionally with nursing and other hospital personnel, and report problems with equipment, supplies, or procedures to the supervisor.
Accept additional duties in different areas of the department as needed, follow established policies, participate in group projects and staff meetings, and help resolve problems.
Identify errors, inefficiencies, and inaccuracies and suggest improvements; develop solutions to departmental problems and identify ways to control costs or generate revenue while providing value.
Measure progress against quality goals and promote the hospital's Attitude is Everything, Core Measure, No Pass Zone, Avatar, and Front Stage/Back-Stage goals.
Coordinate data and reporting needs and provide timely discharge planning.
Contact other organization units and outside-facility staff to obtain, verify, or provide discharge follow-up information.
Answer inquiries and educate patients, families, physicians, and hospital staff about discharge.
Coordinate and supervise air and ground transportation when needed.
Coordinate and supervise cases and referral information for skilled nursing facilities, home health, and durable medical equipment.
Maintain the consistency and integrity of Case Management/Social Services bed-tracking data.
Demonstrate department-specific competencies in medication administration, Basic Life Support, respiratory care, isolation technique, and blood glucose testing.