Registered Nurse Case Manager (RN)

Conifer Health Solutions•Palm Springs, CA

About The Position

GENERAL DUTIES: The individual in this position has overall responsibility for overseeing the clinical plan of care to conform to evidence-based practice and regulatory requirements. This position integrates care coordination, utilization management, and discharge planning. The individual’s responsibilities will include, but not be limited to the following activities: a) medical necessity screening b) care coordination c) discharge planning d) facilitating multi-disciplinary patient care conferences e) managing concurrent disputes f) making the appropriate referrals to other departments (e.g., nutrition, PT/OT/ST) g ) referring complex social issues to Social Service h ) communicating with patients and their families about the plan of care i) collaborating with physicians, office staff and ancillary departments (e.g., lab, pharmacy) j) participating in weekly Complex Case Review k) arranging for post –discharge patient education l) clear, complete and concise documentation in eCCM m ) maintaining accuracy of patient demographic and insurance information n) identifying and documenting potentially avoidable days o) identifying and reporting over and under utilization o) and other duties as assigned. Attends hospital workshop led by the Director of Case Management or designee that includes the Tenet Case Management Model, InterQual, Discharge Planning, Utilization Management, and other topics specific to case management. Extended orientation with selected Case Managers may occur. Information used to perform job: patient data, healthcare staff documentation related to patient care, regulatory and payor requirements Software used to perform job: eCCM: Clinical data interface, InterQual, Case Management documentation, secure faxing, Avoidable Day tracking, Patient Medical Record and HPF, Hospital specific Clinical Software Responsibilities DEPARTMENT SPECIFIC DUTIES: Priority 1: Coordination of clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements. (40% daily, essential). Priority 2: Identify and report variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes work with relevant software and communicating information through clear, complete and concise documentation in eCCM (40% daily, essential). Priority 3: Effective collaboration with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical outcomes (10% daily, essential). Priority 4. Remain current with relevant clinical/case management practices. (10% daily, essential). The metrics below provide an indication of the effectiveness of the individual in this role and may be used for evaluative purposes. The list below is not meant to be exhaustive; other relevant metrics may exist.

Requirements

Current California RN license
Minimum 2 years of acute case management experience
Minimum 5 years bedside experience or 10 years in the relevant clinical specialty (e.g., case manager for pediatrics patients should have pediatric nursing experience)
Excellent organizational skills
Excellent verbal and written communication skills
Ability to lead and coordinate activities of a diverse group of people
Demonstrated critical thinking and problem solving skills
Computer literate
Case Managers hired prior to August 2009 are grandfathered in with the same performance expectations.

Nice To Haves

B.S.N. preferred

Responsibilities

overseeing the clinical plan of care to conform to evidence-based practice and regulatory requirements
integrating care coordination, utilization management, and discharge planning
medical necessity screening
care coordination
discharge planning
facilitating multi-disciplinary patient care conferences
managing concurrent disputes
making the appropriate referrals to other departments (e.g., nutrition, PT/OT/ST)
referring complex social issues to Social Service
communicating with patients and their families about the plan of care
collaborating with physicians, office staff and ancillary departments (e.g., lab, pharmacy)
participating in weekly Complex Case Review
arranging for post –discharge patient education
clear, complete and concise documentation in eCCM
maintaining accuracy of patient demographic and insurance information
identifying and documenting potentially avoidable days
identifying and reporting over and under utilization
Coordination of clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements.
Identify and report variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements.
Effective collaboration with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical outcomes
Remain current with relevant clinical/case management practices.