RN Case Manager Level III/CM Lead, Care Coordination, Full-Time, Days

MarinHealth • Greenbrae, CA

2d • Onsite

About The Position

MarinHealth is an integrated, independent healthcare system with deep roots throughout the North Bay, comprising MarinHealth Medical Center and 55 primary care and specialty clinics. It is affiliated with UCSF Health and has earned high praise and accolades, including being named one of the Top 250 Hospitals Nationwide by Healthgrades. The RN Case Manager, in collaboration with members of the healthcare team, leads the development and implementation of the interdisciplinary plan of care for patients. This role involves determining the appropriate level of care, supervising the provision of the discharge plan of care, and ensuring effective quality and cost-efficient outcomes through concurrent and retrospective case review. This position functions as the key linkage between the physician, staff, and hospital leadership in the day-to-day management of appropriate and efficient patient care and functions as an advisor to the physician with accountability to escalate cases to the Medical Director (as necessary) to ensure the provision of appropriate and effective patient care.

Requirements

• Bachelor of Science degree in Nursing
• 6-8 years or more experience as a case manager in an acute patient care setting in medical/surgical or critical care
• Substantial recent experience in utilization review and/or discharge planning in an acute care setting
• Broad clinical background and knowledge of payer reimbursement and InterQual review guidelines
• Experience as a preceptor, resources and lead in previous role
• Current California RN license
• BLS-HP certification
• Ability to read, write, and follow English verbal and written instructions
• Excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, positive personal influence and negotiation skills
• Leadership skills to delegate, functionally supervise, provide direction/guidance to staff and hold others accountable
• Ability to work independently with a minimum of direction, anticipate and organize work flow, prioritize and follow through on responsibilities
• Strong clinical assessment and critical thinking skills necessary to provide utilization review/discharge planning services appropriate to patients with complex medical, emotional and social needs
• Strong attention to detail and accuracy
• Ability to work in a high volume case load environment and deal effectively with rapidly changing priorities
• Demonstrated ability to work constructively with a broad spectrum of health care professionals
• Assertive and creative in problem solving, system planning and management
• Basic computer skills including use of Electronic Health Record
• Effective both as a team member and leader
• General knowledge of supervisory principles/applications
• Working knowledge of current treatments and their physical and psychosocial sequelae
• Knowledge of individual and family development over the life span
• Knowledge of the influence of cultural and spiritual values on health care
• Basic knowledge of applicable laws, regulations, and accreditation guidelines (e.g. CMS, DHS, Joint Commission, EMTALA)
• Basic knowledge of government and private insurance benefits (e.g. Medi-Cal, Medicare, DRGs, and managed care), including reimbursement requirements
• Knowledge of child, elder and dependent adult and domestic violence reporting requirements
• General knowledge of available health care and community resources appropriate for populations served
• A working knowledge of Inter-Qual criteria

Nice To Haves

• CCM (Certified Case Manager) certification
• ACM (Accredited Case Manager) certification
• National certification in Case Management
• Broad/in-depth knowledge of available health care and community resources appropriate for populations served

Responsibilities

• Works with the healthcare team to ensure the plan of care is expedited and barriers to efficient throughput are identified and corrected.
• Creates a plan of care that outlines the key interventions and outcomes to be achieved each day of the inpatient stay.
• Actively leads multidisciplinary case conferences in developing comprehensive, cost-effective case management plans that span the continuum.
• Makes independent assessments and recommendations regarding course of action in complex situations and recommendations regarding, such as multi-system or special needs.
• Identifies and refers quality and risk management concerns to appropriate level for corrective action plans and trending.
• Proactively solicits physician’s orders for services.
• Identifies target Length of Stay (LOS) by assigning a working DRG in MIDAS within 24 hours of admission.
• Completes an admission review using standardized criteria within 24 hours of admission and documents review outcome.
• Escalates to the Medical Director when criteria is not met and attending physician disagrees with findings.
• Completes a continued-stay review according to policy to assure patient is at the appropriate level of care.
• Monitors the length of stay in comparison with MS-DRG/GMLOS for all patients.
• Completes concurrent review for specified health plans and includes medical necessity documentation to avoid payor denials.
• Ensures that the patient is transitioned to the next level of care as quickly as possible once the patient no longer meets clinical criteria for the current level of care.
• Works with physicians and CDI to ensure that clinical information available in the medical record is accurate and reflects the care rendered to the patient.
• Collaborates with physicians to determine appropriate levels of care for post hospital care, use of hospital resources, and available community resources.
• In a timely manner, communicates pertinent information to third-party payers and managed care organization to obtain authorization for care and prevent denials.
• Reviews, processes, and issues denials to client/responsible party following regulatory guidelines and facility protocols.
• Informs client/responsible party of right of appeal and the appeal process.
• Collects data for the appeals process.
• Identifies avoidable days, intervenes to correct delays, and enters outcomes in MIDAS in a timely manner according to policy and procedure.
• Uses personal judgment within broad guidelines to initiate review of inappropriate utilization by physicians and follows-through to resolution (e.g., attending, department chair, utilization management medical director).
• Completes an initial assessment within 24 hours of admission and documents findings in the electronic health record.
• Reviews initial hospital admission and gathers additional medical, psychosocial and financial data from needs assessment, client/family, physicians, and other health care providers.
• Determines risk level and identifies client’s service needs.
• Formulates a discharge plan after completing a face-to-face interview and discusses available/appropriate care options and obtaining input from the patient/family and physician, healthcare team, insurance companies, and community-based support services.
• Collaborates with physicians to facilitate timely resolution of situations such as client concerns or need for referrals to expedite the discharge plan.
• Identifies potential problems, prevents and/or resolves variances to the case management plan.
• Effectively deals with resistance and conflict in working with member of the patient care team, physicians, clients, and families.
• Implements all aspects of the discharge plan of care, intervening in an appropriate and timely basis when difficulties arise.
• Mobilizes resources to effect rapid and timely movement of the patient through the system and promote timely discharge in keeping with quality indicators.
• Identifies and mobilizes patient’s and family’s strengths to optimize use of healthcare and community resources.
• In coordination with patient/family wishes, guides/assists in securing needed post discharge services, which may require negotiating for services covered but not readily available.
• Implements the discharge plan to include all the necessary referrals and authorizations as identified by federal, state, and local insurance regulatory agencies and offers patient choice per regulatory guidelines.
• Interfaces with Social Work on discharge planning issues for resolution and assures barriers are addressed in a timely manner.
• Actively participates in department meetings and operations, including process development or improvement (e.g., department orientation, internal mentor/training programs and initiates, disease and population management strategies, appropriate measures for evaluation of outcomes) and establishment of department goals, objectives, and budget.
• Ensures all applicable department and regulatory targets for productivity and department performance process improvement are attained (e.g., hospital length of stay, average cost per discharge, and re-admission rates, etc.).
• Complies with all reporting requirements for mandated, risk management, and other medical/legal situations consistent with confidentiality policies and department standards.
• Actively contributes to the development and maintenance of a care delivery system which is sensitive to individual patient needs, promotes effective resource utilization, and supports physician practice, while emphasizing coordination across the continuum.
• Positively contributes to team’s decision-making process, effectively collaborates with other team members on interdependent tasks, and actively supports implementation of plans to accomplish team objectives.
• Prepares and conducts presentations to multidisciplinary teams related to special projects, case management, etc.
• Adheres to department and facility policies and procedures and supports philosophies and initiatives.
• Maintains accurate, current, and legible patient records using approved forms and format, according to department and entity standards, including patient assessments, plans, interventions, patient/family involvement, outside agency communications, and interdisciplinary contacts.
• Actively participates in ongoing department interviews for Case Managers and Department Assistants, effectively recommending selected applicants for hire.
• Recommends or provides necessary training to staff.
• Attends and participates in community-based committees and task forces, when applicable and staff is available.
• Other duties as assigned.

Benefits

• Reasonable accommodation during the application process for qualified applicants with disabilities
• Reasonable accommodation(s) to qualified individuals with disabilities as part of the application step
• Equal Employment Opportunity (without regard to race, color, religion, national origin, sexual orientation, gender identity, protected veteran status or disability status, and any other classifications protected by federal, state, and local laws)
• Welcome and encourage diversity in the workplace

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Number of Employees: 501-1,000 employees