RN, Case Manager III (UR)

MemorialCare • Long Beach, CA

7d • Onsite

About The Position

The Case Manager III is a licensed professional who plans, coordinates and facilitates the ongoing care and appropriate discharge plan of a specific caseload of patients through the continuum of care. The case manager III collaborates with members of the health care team, the patient, and their family to assure effective, efficient, and appropriate care and outcomes. The incumbent is accountable for education, monitoring, utilization and evaluation of medical outcomes.

Requirements

• Strong verbal and written communication skills with the ability to communicate well with people from diverse socioeconomic backgrounds.
• Knowledgeable of criteria for medical necessity for each level of care through the continuum of care.
• Knowledge of reimbursement related to MediCare, MediCal, Capitation, and Managed Care is required.
• Three to five years acute care or home health experience plus prior experience in Quality Improvement, Case Management, Discharge Planning or Utilization Management required.
• Current California RN License.

Nice To Haves

• BSN or Bachelors degree in health or related field preferred

Responsibilities

• Independently manages a specific case load of patients as identified by the Resource Management Department and CareLines.
• Analyzes patient information and assess each patient’s functional status and decision making ability in relation to the continuum of care and discharge needs.
• Collaborates with the health care team, patient, and family in planning and facilitating the achievement of expected outcomes for patients.
• Evaluates each treatment plan for appropriate quality outcomes and utilization of resources.
• Works collaboratively with the health care team to provide education, resources, and referrals as needed for each patient and their family or caretaker.
• Facilitates coordination among health care professionals, services, and settings involved in the patient’s care, with a focus on enhancing patient satisfaction.
• Actively communicates with nursing leadership, CareLine physician directors, and Medical Directors on quality issues.
• Refers concerns to various Medical Staff Committees and CareLines through required documentation, including but not limited to the Clinical Pertinence Review Form.
• Maintains professionalism and provides ongoing education to the health care team regarding the case manager’s role.
• Works collaboratively and proactively with payors in managing patient resources.
• Assures the hospital receives appropriate reimbursement through collaboration with the health care team and provides timely clinical review, as well as retroactive review for unbilled accounts.
• Utilizes the billing system to analyze charges vs. reimbursement and contract information.
• Incorporates knowledge of medical necessity, CareLine protocols, and MAPs to evaluate for appropriateness of admissions, continued stay, and discharges.
• Refers cases, as appropriate, for review to the Combined Resource Management Committee and other Medical Staff Committees as needed.

Benefits

• High quality health insurance plan options
• $20,000 signing bonus available to external hires new to MHS employment, contingent upon satisfaction of employment requirements.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level