LVN Care Coordinator - Utilization Management - SRS Copley - Day

Sharp HealthCare•San Diego, CA

3d•$34 - $49

About The Position

To provide discharge planning and coordination of care for members hospitalized in the acute care setting in collaboration with the Hospitalist team, SRS primary care physician, and ancillary staff to ensure cost effective quality service throughout the continuum of care.

Requirements

Graduate of an accredited Licensed Vocational Nurse (LVN) program.
California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians -REQUIRED
Knowledge and ability to utilize community resources.
Knowledge of and experience with on-line computer systems.
Excellent verbal and written communication skills; strong interpersonal skills.
Ability to work independently and effectively with physicians, facility staff, health plans, department staff, and various members of the health care team.
Knowledge of available community resources and current standards of clinical practice.
Knowledge of managed care and Health Plan contracts.
Understanding of the ICD and CPT coding.
Ability to identify medically necessary care and offer alternatives for quality, cost effective care when services cannot be authorized.
Good computer skills.
Strong organizational skills.

Nice To Haves

1 Year experience in the acute patient care, SNF, home health, or hospice settings.
Experience as a case manager or discharge planner interacting with managed care payers.
Experience with InterQual or Milliman Guidelines.

Responsibilities

Reviews every patient under assigned workload initially and reviews based on review of care plan.
Makes rounds and sees every patient identified per departmental guidelines during hospital stay beginning with the admission review of the case manager and reviews with the Case Manager Lead, as needed.
Keeps SRS Leadership informed of any adverse development, delay in discharge or services, readmissions to acute or visit to the Emergency Department.
Informs Director, QI/UM of any quality issues.
Attends hospitalists rounds, as required, to discuss high risk patients requiring case management follow up.
Attends clinical in-services or required operational/clinical training sessions.
Demonstrates knowledge of Health Plan contracts and Health Plan benefits
Coordinates services and supplies through SRS (or health plan, as applicable) contracted vendors.
Supports compliance with all applicable regulatory and health plan guidelines for issuance with notices of non-coverage, etc.
Identifies services that are not medically necessary and/or not covered benefits and accurately follows Health Plan and/or Medicare Guidelines when issuing denials.
Ensures that all denials for medical necessity are issued under the direction of the Medical Director or designee.
Assists with transfers, when necessary.
Demonstrates knowledge of department policies and procedures
Demonstrates knowledge of Health Plan contracts and Health Plan benefits.
Coordinates services and supplies through SRS (or health plan, as applicable) contracted vendors.
Provides authorization as needed for DME or other services for skilled nursing facility placement or home care.
Ensures compliance with all applicable regulatory and health plan guidelines for issuance of notice letters.
Assures that letters are issued accurately and served timely to members or responsible party.
Ensures that all denials for medical necessity are issued under the direction of the appropriate Medical Group Physician Representative.
Collaborates with SCMG Medical Group Appeals when necessary.
Documents Initial discharges follow up three days (or sooner depending on the case) after the Initial Screen by the Case Manager and continues to follow up every three days for the duration of hospitalization.
Discusses with hospitalist the discharge plan and barriers in rounds, in person or by phone.
Tracks and documents key performance measures related to inpatient management per requirements.
Reviews patient medical record including, but not limited, to progress notes, orders, vital signs, laboratory results.
Communicates with the PCP and also discuss with the PCP's nurse if the physician is unable to come to the phone for patient issues, when needed.
Performs data entry related to patient management activities utilizing designated computer systems.
Complies with contracted health plan requirements for case management activities performed in a manner consistent with SRS policies and procedures.
Works collaboratively with the Hospitalist Team and Case Management staff to ensure smooth transitions throughout the continuum of care.
Confirms that the patient is discharging to the appropriate level of care and coordinates discharge accordingly.
Communicates with patient, their family, the physician and the interdisciplinary team, as appropriate, regarding insurance coverage, discharge planning support, and post discharge care needs.
Assists and performs discharge planning functions based on specific protocols, as needed, and promotes timely assessment of discharge planning needs of the patient by within three days from the initial assessment by the case manager and at least every three days for the duration of the hospitalization.
Facilitates timely referrals to social work and/or patient financial services for financial screening on patients requiring long term custodial placement.
Accurately documents patient's clinical condition and/or level of care and maintains accurate, and timely data on each patient per policy and procedures.
Communicates and collaborates with physician Health Care team and patient and/or family to explore alternative care option if patient does not meet acute or skilled level of care.
Communicates with the Quality Management Department regarding any quality of service or quality of care issues encountered in the course of review.
Serves as a resource for staff (as needed), and ancillary personnel within and outside the hospital regarding discharge disposition for SRS.