Case Manager - Sharp Chula Vista - FT - Days

Sharp HealthCare•Chula Vista, CA

About The Position

The RN CM II assesses, develops, implements, coordinates, and monitors a comprehensive plan of care for each patient and family in collaboration with physicians, social workers, and the interdisciplinary team in inpatient and emergency department settings. The role combines clinical and quality considerations with regulatory, financial, and utilization review requirements to ensure patients receive care in the appropriate setting and at the appropriate level. It balances individual clinical needs with efficient, cost-effective resource use while promoting quality outcomes. The position requires advanced critical thinking, problem-solving, and time-management skills and partners with ICM leadership to mentor and precept new hires, including CMI, social workers, LVN Care Coordinators, and CRCs. The RN CM II coordinates care and discharge planning, performs utilization review and management, supports regulatory and contractual compliance, and collaborates with the healthcare team to improve length of stay, care transitions, readmissions, patient experience, and other quality outcomes. Work includes patient and family interviews, interdisciplinary rounds, discharge arrangements, status and level-of-care recommendations, payer authorizations, documentation, and escalation of complex cases or quality concerns. The role may also lead or participate in special projects and serve as a designated resource point of contact.

Requirements

Bachelor's degree in Nursing or equivalent degree.
Two years of recent pertinent clinical experience as defined by the CBA.
Three years of acute-care nursing experience or case-management experience.
Three years of experience in case management, utilization review, or care coordination.
Current California Registered Nurse (RN) license from the California Board of Registered Nursing.
Advanced PC, data-management, and analysis skills.
Understanding of payer eligibility and reimbursement regulations and their impact on the continuum of care.
Knowledge of community resources used to coordinate safe discharges from acute-care and emergency-department settings.
Excellent interpersonal skills and ability to work effectively with individuals, teams, and across disciplines.
Excellent oral and written communication and negotiation skills.
Ability to work collaboratively with social workers and other internal and external interdisciplinary team members.
Organizational and time-management skills, including the ability to prioritize multiple tasks.
Ability to mentor and lead a team.
Ability to work independently with minimal supervision, manage multiple assignments, solve problems, and pay close attention to detail.

Nice To Haves

Master's degree.
Certified Case Manager (CCM) certification from the Commission for Case Manager Certification.
Accredited Case Manager (ACM) certification from the American Case Management Association.
Experience with MCG.

Responsibilities

Assess, develop, implement, coordinate, and monitor comprehensive patient and family plans of care with physicians, social workers, and the interdisciplinary team.
Make timely referrals to ensure patients receive appropriate care in the appropriate setting and at the appropriate level of care.
Coordinate patient progression through hospitalization and the continuum of care, balancing clinical needs with efficient and cost-effective resource use.
Collaborate with healthcare teams to support organizational goals, including reducing length of stay, denials, and avoidable readmissions and improving care transitions and patient experience.
In emergency departments, provide preadmission status recommendations and coordinate integrated discharge plans for patients discharged to a lower level of care.
Recommend and document patient classification, status, and level of care for admissions using established criteria.
Interview patients and families within 24 hours of admission regarding anticipated post-hospitalization needs; document plans and interventions in the EMR and supporting case-management software.
Obtain and document patient choice in accordance with state and federal requirements; develop and document daily and stay plans with patients, families, providers, and nursing staff.
Lead daily multidisciplinary care-coordination rounds, update plans, and facilitate coordination of services.
Initiate and document discharge plans, including early referrals and authorizations for LTAC, SNF, rehabilitation, homecare, DME, and infusion services; prepare patients and families for discharge and arrange discharge pickup appointments.
Collaborate with social work partners on patient and family conferences and ensure safe, effective handovers to the next level of care.
Work with ambulatory care managers, clinics, medical groups, complex-care case managers, homecare, and sub-acute liaisons as appropriate.
Support Patient and Family Centered Care goals with nursing managers and staff, and facilitate early-day discharges to improve capacity management.
Document avoidable days, participate in efforts to reduce discharge barriers, and collaborate with CRCs and clinical assistants to direct referrals to appropriate network providers and obtain service authorizations.
Deliver and document mandated patient communications; oversee preparation and delivery of non-coverage letters.
Identify and escalate potential quality variances, document them according to guidelines, and review readmissions within 30 days to identify discharge issues and report findings.
Conduct point-of-entry or admission reviews within 24 hours using evidence-based care-guideline software; document findings, anticipated length of stay, and related communications.
Conduct daily concurrent reviews, determine appropriate status and level of care, resolve status/order mismatches with providers, and ensure required Medicare documentation and Condition Code 44 processes are followed.
Manage observation patient transitions, communicate with third-party payers for authorizations, and obtain and communicate approved days or length of stay to the care team.
Refer defined cases for medical secondary review; advise Revenue Cycle/HIM on RAC appeal decisions and denials, contribute to appeals, and share findings with providers.
Identify cost-reduction opportunities, participate in utilization-management venues, and escalate cases to a Physician Advisor or Medical Director when appropriate.
Manage multiple assignments, prioritize workload, handle complex cases, and lead or participate in special projects as assigned.
Serve as a designated point person or resource contact and mentor and precept new hires.
Maintain current knowledge of case management, utilization management, discharge planning, and applicable Sharp, federal, state, and private-insurance guidelines.
Perform other duties as needed.