Case Manager - Care Coordination - Full Time 8 hours Days (Union, Non-Exempt)

University of Southern California•Arcadia, CA

4d•Onsite

About The Position

The Case Manager position supports the physician and interdisciplinary team in patient care, aiming to enhance clinical outcomes and patient satisfaction while managing costs and providing accurate payer information. This role integrates utilization management, care facilitation, and discharge planning. The Case Manager is responsible for a patient caseload, planning to meet patient needs, manage length of stay, and optimize resource utilization. Key functions include facilitating pre-certification and payer authorization, coordinating care across the continuum, removing barriers to care delivery and reimbursement, applying process improvement, coaching clinical documentation, and serving as a clinical resource for coders to ensure accurate reflection of severity of illness and intensity of service.

Requirements

Associate’s Degree Nursing
Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.
Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
Excellent interpersonal communication and negotiation skills.
Strong organizational and time management skills, as evidenced by a capacity to prioritize multiple tasks and role components.
Understanding of pre-acute and post-acute venues of care and post-acute community resources.
Strong analytical, data management, and PC skills.
Registered Nurse - RN (CA Board of Registered Nursing)
Basic Life Support (BLS) Healthcare Provider from American Heart Association

Nice To Haves

3 years Clinical experience in Utilization Review and Discharge Planning in an Acute Hospital strongly preferred.

Responsibilities

Actively participates in clinical performance improvement activities.
Applies approved InterQual criteria to monitor appropriateness of admissions and continued stays and documents findings based on department standards.
Assist in the compilation of physician profile data regarding LOS, resource utilization, denied days, cost, case mix index, patient satisfaction, and quality indicators.
Assists in the collection and reporting of financial indicators including case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials, and appeals.
Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation.
Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated caseload; monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting of diagnostic testing, completion of treatment plan and discharge plan, modification of plan of care, as necessary, to meet the ongoing needs of the patient, communication to third-party payers and other relevant information to the care team, assignment of appropriate levels of care, completion of all required documentation in Affinity GUI screens and patient records.
Collaborates/communicates with external case managers.
Collects delay in service data and data for specific performance and/or outcome indicators as determined by the director.
Communicates with Financial Counselor to facilitate covered day reimbursement certification for assigned patients.
Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed.
Completes utilization management for assigned patients.
Coordinates/facilitates patient cares progression throughout the continuum.
Documents relevant discharge planning information in the Affinity GUI System according to department standards.
Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the health care team and are documented as necessary to ensure continuity of care.
Ensures/maintains plan consensus from patient/family, physician, and payer.
Facilitates transfer to other facilities.
Identifies at-risk populations using approved screening tool and follows established reporting procedures.
Initiates and facilitates referrals to the Home Health Liaison for home health care, hospice, and medical equipment and supplies.
Issues Notices of Non-coverage per hospital policy.
Manages all aspects of discharge planning for assigned patients.
Meets directly with patient/family to assess needs and develop an individualized plan in collaboration with the physician.
Monitors all transfer DRG’s.
Monitors length of stay (LOS) and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
Perform 100% UR Review on all Medicare One-Day admissions.
Proactively identifies and resolves delays and obstacles to discharge.
Refers appropriate cases for social work intervention based on department criteria.
Refers cases and issues to physician advisor in compliance with department procedures and follows up as indicated.
Seeks consultation from appropriate disciplines/ departments as required to expedite care and facilitate discharge.
Uses data to drive decisions and plan/implement performance improvement strategies related for assigned patients, including fiscal, clinical, and patient satisfaction data.
Uses quality screens to identify potential issues and forwards information to the PI department.
Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
Works collaboratively and maintains active communication with physicians, nursing, and other members of the multidisciplinary care team to effect timely, appropriate patient management.