Per Diem RN - Case Manager - Sharp Memorial Hospital - PD - Days

Sharp HealthCare•San Diego, CA

2d•Onsite

About The Position

The RN CM assesses, develops, implements, coordinates and monitors a comprehensive plan of care for each patient/family in collaboration with the physician, social worker and all members of the interdisciplinary team in the inpatient and emergency department patient care areas. This position requires the ability to combine clinical/quality considerations with regulatory/financial/utilization review demands to assure patients are receiving care in the appropriate setting and level of care. The position creates a balance between individual clinical needs with the efficient and cost effective utilization of resources while promoting quality outcomes.

Requirements

3 Years Recent acute care nursing experience or case management experience.
California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED

Nice To Haves

Bachelor's Degree in Nursing
Certified Case Manager (CCM) - Commission for Case Manager Certification -PREFERRED
PC, data management and analysis skills
Experience with InterQual, and or MCG and Allscripts Care Management
Excellent interpersonal skills, as demonstrated by the ability to work effectively with individuals and or teams, and across disciplines.
Excellent communication and negotiation skills as demonstrated in oral and written forms.
Ability to work in a collaborative partnership model with Social Workers and other members of the interdisciplinary team, both internal and external.
Organizational and time management skills, as evidence by capacity to prioritize multiple tasks.

Responsibilities

Assesses, develops, implements, coordinates and monitors a comprehensive plan of care for each patient/family in collaboration with the physician, social worker and all members of the interdisciplinary team in the inpatient and emergency department patient care areas.
Combines clinical/quality considerations with regulatory/financial/utilization review demands to assure patients are receiving care in the appropriate setting and level of care.
Creates a balance between individual clinical needs with the efficient and cost effective utilization of resources while promoting quality outcomes.
Makes timely referrals to ensure that the patient is receiving the appropriate care, in the appropriate setting and using the appropriate utilization standards as set by community and professional standard as adopted by the medical staff.
Assures that the patients from all age groups proceed efficiently through the course of hospitalization and beyond through the continuum of care.
Relates and communicates positively, effectively, and professionally with others; is assertive and consistent in following and/or enforcing policies; works calmly and responds courteously when under pressure; leads, supervises, teaches, collaborates and accepts direction.
Works closely with the healthcare team in reaching unit, facility, and system/network organization goals including reductions in length of stay, decreasing denials, improvement of care transitions, and reduction in avoidable readmissions, improved patient experience, and other quality initiatives.
In the emergency departments, works collaboratively with other members of the interdisciplinary team to develop relationships and provide pre admission status recommendations for admissions as well as implement a comprehensive, integrated discharge plan from the emergency department (ED) for patients who are being discharged to a lower level of care.
Recommends and documents patient classification (status and level of care) for all admissions utilizing established criterion sets.
Maintains compliance contractual and regulatory compliance with medical groups as applicable and the hospital.
Interviews each patient/family within 24 hours of admission for anticipated needs post hospitalization.
Documents the plan and interventions in the EMR (e.g., Cerner), and case management software (e.g., Allscripts Care Management).
Develops and documents a plan for the day and plan for the stay with patient, family, providers, and nursing staff.
Leads the daily care coordination (multidisciplinary) rounds, updates the plan, and facilitates necessary coordination of services.
Documents and initiates discharge plan including early referrals and authorization for LTAC, SNF, Rehab, homecare, DME and infusion services.
Prepares patient/family for discharge.
Documents expected discharge date per protocol and arranges discharge pick up appointment with family or significant other.
In collaboration with SW partner, follows standards for routine patient/family conference.
Ensures effective and safe patient handovers to next level of care; works closely with ambulatory care manager (ACM) at the system level, in clinics, with SCMG and other complex care Case Managers as appropriate, and homecare and sub-acute liaisons.
Supports the nursing Model of Care by working closely with nursing managers and staff to achieve Patient and Family Centered Care goals: respect and dignity, information sharing, participation and collaboration.
Facilitates increased volume of cases discharged early in the day to improve capacity management.
Collects and documents avoidable days information in appropriate case management software, e.g., Allscripts Care Management.
Participates in venues to reduce barriers to discharge.
Collaborates with Clinical Resource Coordinators (CRCs/clinical assistants) to assure appropriate referrals for care and services are directed to appropriate network providers, and obtains prior authorization for in network and out of network services as appropriate.
Provides timely delivery of regulatory and mandated patient communications and correspondence.
Oversees preparation, delivery and documentation of non-coverage letters.
Identifies and escalates potential quality variances to management and documents per guidelines.
Interviews all patients with an admission within 30 days to determine what went wrong in the discharge. Documents as appropriate in Cerner and Allscripts Care Management and provides information to the department head as indicated.
Conducts initial review at POE or within 24 hours of admission utilizing appropriate care guidelines software.
Documents findings in CM software, e.g., Allscripts Care Management.
Identifies anticipated LOS and documents in Allscripts Care Management, communicates to healthcare team.
Conducts daily concurrent reviews per protocol/policy and payer request.
Utilizes appropriate care guideline software to identify the correct patient status and level of care.
Works with attending provider to assure correct status, if status and order does not match; works with provider to resolve conflict and documents interventions in Allscripts Care Management.
Assures correct documentation is present for 2MN benchmark and presumption.
Assures Medicare Inpatient to observation status changes follow Condition Code 44 requirements.
Actively works observation patient list assuring transitions to next level of Care.
Communicates as indicated with third party payers to obtain necessary authorization for reimbursement of services.
Obtains approved days/LOS from provider and communicates this to the care team.
Refers defined cases for medical secondary review and shares findings with providers.
Provides advice to Revenue Cycle/HIM regarding RAC decision to appeal, denials, input into appeals, shares findings with providers.
Reviews all cases with readmission within 30 days; reports findings in Care Management software such as Allscripts.
Identifies opportunities for cost reduction and participates in appropriate utilization management venues.
Escalates and refers cases for consultation with Physician Advisor or Medical Director as appropriate.
Oversees preparation, delivery and documentation of non-coverage letters.