Case Manager, RN - Ambulatory Case Management

Cedars-Sinai Medical Center•Beverly Hills, CA

About The Position

The Case Manager is responsible for managing patient care while patients are hospitalized and after discharge from various care settings. In collaboration with Inpatient Specialty Program hospitalists, the Case Manager supports patients from admission through discharge by assessing needs, coordinating care, communicating with health plans, conducting concurrent reviews to determine service appropriateness, and helping ensure care is delivered with quality and cost-effectiveness. The role includes assessing patients within 24 hours of admission, reviewing medical necessity and level of care with hospitalists, planning discharges, coordinating transitions and follow-up care, authorizing appropriate covered services, and arranging referrals and appointments. The Case Manager also communicates transition-of-care information to members or their responsible parties and refers patients who need outpatient oversight to an Ambulatory Case Manager.

Requirements

Bachelor’s degree.
Graduation from an accredited school of nursing.
Three years of nursing experience.
One to two years of previous case management experience in an outpatient setting.
Current California RN license.

Responsibilities

Meet with patients within 24 hours of admission and conduct an initial assessment.
Consult with the assigned hospitalist during daily morning rounds regarding disposition planning and the appropriateness of each day of the patient’s stay.
Review admissions and continued stays with the hospitalist for medical necessity, appropriateness of care, and level of care; use Milliman and InterQual guidelines as necessary.
Plan discharges and conduct care assessments.
Submit necessary clinical information to the health plan in the accepted format, such as MIDAS or telephonic review, and coordinate health plan communication with the assigned hospitalist as appropriate.
Coordinate with nurse practitioners and case managers assigned to skilled nursing facilities for continued review and follow-up.
Communicate the transition-of-care process, expected changes in health status and care plan, and staff contacts to the member or responsible party.
Authorize appropriate services based on covered benefits and necessity of care in members’ homes or residences, acute care, skilled nursing facilities, rehabilitation facilities, home health care, and custodial care or board-and-care facilities.
Coordinate discharge planning and alternative treatment plans with primary care providers, hospitalists, and specialists as appropriate.
Secure outpatient follow-up appointments and schedule tests or outpatient procedures with appropriate health care providers.
Refer patients who need oversight of outpatient care and compliance to an Ambulatory Case Manager to help avoid unnecessary readmissions.
Coordinate referrals and secure appointments with disease management programs.