Case Manager (TC) (CNA)

Adventist Health•Templeton, CA

1d•Onsite

About The Position

The RN Case Manager is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity and to assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including: Utilization Management supporting medical necessity and denial prevention, Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction, Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care, Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy, and Education provided to physicians, patients, families and caregivers. The individual’s responsibilities include the following activities: accurate medical necessity screening and submission for Physician Advisor review, care coordination, transition planning assessment and reassessment, implementation or oversight of implementation of the transition plan, leading and facilitating multi-disciplinary patient care conferences, managing concurrent disputes, making appropriate referrals to other departments, identifying and referring complex patients to Social Work Services, communicating with patients and families about the plan of care, collaborating with physicians, office staff and ancillary departments, leading and facilitating Complex Case Review, assuring patient education is completed to support post-acute needs, timely complete and concise documentation in Case Management system, maintenance of accurate patient demographic and insurance information, identification and documentation of potentially avoidable days, identification and reporting over and underutilization, and other duties as assigned. This position is represented by CNA.

Requirements

Graduate of a school of nursing: Required
Two years acute care RN experience: Required
Current RN license in state of practice: Required
Registered Nurse (RN) license in state of practice: Required

Nice To Haves

Experience in utilization review, discharge planning and/or home health: Preferred
Recent experience in acute care hospital case management: Preferred
Accredited Case Manager (ACM): Preferred

Responsibilities

Facilitate care along a continuum through effective resource coordination.
Ensure care is provided at the appropriate level of care based on medical necessity.
Assess patients for transition needs to promote timely throughput, safe discharge, and prevent avoidable readmissions.
Perform accurate medical necessity screening and submission for Physician Advisor review.
Coordinate care and conduct transition planning assessment and reassessment.
Implement or oversee the implementation of the transition plan.
Lead and facilitate multi-disciplinary patient care conferences.
Manage concurrent disputes.
Make appropriate referrals to other departments.
Identify and refer complex patients to Social Work Services.
Communicate with patients and families about the plan of care.
Collaborate with physicians, office staff, and ancillary departments.
Lead and facilitate Complex Case Review.
Ensure patient education is completed to support post-acute needs.
Complete timely and concise documentation in the Case Management system.
Maintain accurate patient demographic and insurance information.
Identify and document potentially avoidable days.
Identify and report over and underutilization.
Assist physicians in making admission decisions considering observation, outpatient, and inpatient status and payor guidelines.
Demonstrate clear and effective communication with nursing and physicians.
Work cooperatively with nursing, dietary, P.T., and social services to develop a safe discharge plan.
Maintain patient, co-worker, and hospital privacy.
Develop a discharge plan that is safe and meets the patient’s needs.
Obtain psycho/social assessment according to discharge planning protocol for all age groups.
Review medical history, physical examination, and all available assessment data to assist in developing the discharge plan.
Collect information needed to begin discharge planning in a timely manner, and initiate contact with patient and/or family.
Review care and progress on assigned patients as often as necessary, but no less than every 72 hours and document in the discharge planning notes.
Coordinate team or family conferences as needed on complex patients.
Ensure that the patient is medically stable for discharge from the inpatient setting and that the patient and family are prepared educationally, emotionally, and functionally for discharge.
Maintain a reference network of health systems and community resources in order to adequately plan for discharge.
Use Interqual and CMS programs for assessment and discharge planning.
Assist in the development and education of new staff members.
Attend and participate in staff meetings.
Complete mandatory modules as required.
Successfully adapt to changes in the unit, environment, and workflow.
Obtain optimal coverage for patients by furnishing appropriate medical information to insurance carriers.
Notify review companies of planned treatment, length of stay, progress, etc., and obtain initial certification.
Refer appropriate patients to the MEP (financial counselor).
Present letters of denial of coverage when appropriate.
Perform other job-related duties as assigned.