Nurse, Care Management

Alameda Health System•Oakland, CA

About The Position

Responsible for coordinating continuum-of-care and discharge-planning activities for an assigned caseload of patients. Develops plans of care and discharge plans, monitors clinical activities, recommends alternative levels of care, and identifies cost-effective protocols. Care Management includes care coordination, compliance, transition coordination, and utilization management.

Requirements

Associate Degree in Nursing.
At least three years of acute-care nursing experience.
Active Registered Nurse licensure in the State of California.
Active Basic Life Support certification issued by the American Heart Association.
Advanced life support certifications may be required according to unit or department specialty and patient care policies.
CPI (Crisis Prevention Intervention) training is required for all positions at John George Psychiatric Pavilion and certain Emergency Department positions.

Nice To Haves

Bachelor’s degree in Nursing.
Master’s degree in Nursing.
Medical/surgical or critical-care experience and a broad clinical background.
Within the last three years, experience in case management in an acute setting or utilization review at a medical group or health plan.
Certification in Case Management through CCMC or ACM.
Bilingual ability.

Responsibilities

Coordinate utilization review functions, including responding to payor requests for concurrent and retrospective review information and addressing Medicare and MediCal requirements, avoidable days, and quality issues.
Apply medical necessity criteria to determine level of care and assess whether clinical interventions and admission status are appropriate. Use McKesson InterQual clinical guidelines and refer questionable cases to the CM Manager or physician advisor.
Take appropriate action when cases do not meet criteria, escalating to the attending physician and Care Management physician advisor when there are concurrent denials. Prepare case reports and document treatment plans, progress notes, and discharge information as required by regulations and department standards.
Reassess patients when their conditions change and revise care plans as appropriate.
Develop, evaluate, and coordinate comprehensive discharge plans with patients and families, physicians, nursing, social work, other healthcare providers, and agencies. Complete an initial assessment within 24 hours of admission and document findings in the electronic health record.
Process referrals and authorizations in accordance with federal, state, and local insurance regulations, while offering patient choice as required by regulation.
Identify potential problems and prevent or resolve barriers to discharge planning, in coordination with the social work team member.
Mobilize resources to facilitate timely patient movement through the system and meet discharge targets established by AHS.
Identify and mobilize patient and family strengths to optimize use of healthcare and community resources, and assist in securing post-discharge services in accordance with patient and family wishes.
Collaborate with Care Management teams, including care transition teams and teams at other facilities, to arrange timely follow-up for high-risk patients and ensure complex patients are linked to community services before discharge.
Provide community resource education and coaching focused on patient self-management. Ensure continuity of care through communication in rounds and written documentation, level-of-care recommendations, transfer coordination, discharge planning, and obtaining authorizations or approvals for outside services.
Communicate with physicians and multidisciplinary health team members to support continuity of care, teamwork, effective resource utilization, and appropriate levels of care.
Make independent assessments and recommendations regarding courses of action in complex situations.
Confirm that applicable department and regulatory performance targets and process-improvement goals are attained, including readmissions, throughput, and length of stay.