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

Sharp HealthCare•San Diego, CA

About The Position

The RN Case Manager assesses, develops, implements, coordinates, and monitors comprehensive plans of care for patients and families in inpatient and emergency department settings. Working with physicians, social workers, and the interdisciplinary team, the RN Case Manager balances clinical and quality considerations with regulatory, financial, and utilization review requirements to ensure patients receive care in the appropriate setting and at the appropriate level. The role supports quality outcomes while promoting efficient, cost-effective use of resources. The RN Case Manager coordinates care and discharge planning, conducts utilization review, recommends and documents patient classification and level of care, and helps ensure regulatory and contractual compliance. The position works with patients, families, providers, nursing staff, payers, and community care partners to coordinate services and transitions across the continuum of care. It also contributes to organizational goals related to length of stay, denials, care transitions, avoidable readmissions, patient experience, and other quality initiatives.

Requirements

Three years of recent acute care nursing experience or case management experience.
California Registered Nurse (RN) license from the California Board of Registered Nursing; required.
PC, data management, and analysis skills.
Excellent interpersonal skills and ability to work effectively with individuals and teams across disciplines.
Excellent oral and written communication and negotiation skills.
Ability to work collaboratively with social workers and other internal and external interdisciplinary team members.
Organizational and time-management skills, including the ability to prioritize multiple tasks.

Nice To Haves

Bachelor's degree in Nursing.
Certified Case Manager (CCM) credential from the Commission for Case Manager Certification; preferred.
Experience with InterQual, MCG, and Allscripts Care Management.

Responsibilities

Assess, develop, implement, coordinate, and monitor comprehensive patient and family care plans in collaboration with physicians, social workers, and the interdisciplinary team.
Maintain current knowledge of case management, utilization management, discharge planning, and applicable Sharp, federal, state, and private insurance guidelines.
Make timely referrals and help ensure patients receive appropriate care in the appropriate setting and at the appropriate level.
Coordinate care for patients of all age groups through hospitalization and across the continuum of care.
Communicate professionally and effectively; collaborate, teach, lead, supervise, accept direction, and consistently follow or enforce policies.
Work with healthcare teams to support goals such as reducing length of stay and denials, improving care transitions and patient experience, and reducing avoidable readmissions.
In emergency departments, collaborate on pre-admission status recommendations and integrated discharge plans for patients going to a lower level of care.
Recommend and document patient classification, status, and level of care for admissions using established criteria.
Interview each patient and family within 24 hours of admission about anticipated post-hospitalization needs and document plans and interventions in the EMR and case management software.
Develop and document the plan for the day and plan for the stay with patients, families, providers, and nursing staff.
Lead daily multidisciplinary care coordination rounds, update plans, and facilitate coordination of services.
Initiate and document discharge plans, including early referrals and authorizations for LTAC, SNF, rehabilitation, homecare, durable medical equipment, and infusion services.
Prepare patients and families for discharge, document expected discharge dates, and arrange discharge pickup with family or a significant other.
Follow patient and family conference standards with the social work partner and ensure safe, effective handovers to the next level of care.
Coordinate with ambulatory care managers, clinics, medical groups, complex care case managers, homecare providers, and sub-acute liaisons as appropriate.
Support Patient and Family Centered Care goals in partnership with nursing managers and staff.
Facilitate early-day discharges, document avoidable days, and participate in efforts to reduce discharge barriers.
Collaborate with clinical resource coordinators to direct referrals to appropriate network providers and obtain prior authorizations for in-network and out-of-network services as appropriate.
Deliver and document required regulatory and mandated patient communications, including non-coverage letters.
Identify and escalate potential quality variances and document them according to guidelines.
Interview patients readmitted within 30 days to determine what went wrong with discharge, document findings in Cerner and Allscripts Care Management as appropriate, and provide information to the department head as indicated.
Conduct initial utilization reviews at point of entry or within 24 hours of admission using appropriate care guideline software, and document findings in case management software.
Identify anticipated length of stay and communicate it to the healthcare team; conduct daily concurrent reviews according to protocol, policy, and payer requests.
Use care guidelines to determine appropriate patient status and level of care; work with attending providers to resolve status and order mismatches and document interventions.
Ensure documentation supports the 2MN benchmark and presumption, and that Medicare inpatient-to-observation status changes meet Condition Code 44 requirements.
Manage the observation patient list and support transitions to the next level of care.
Communicate with third-party payers to obtain authorization for reimbursement, obtain approved days or length of stay from providers, and share this information with the care team.
Refer defined cases for medical secondary review and share findings with providers.
Advise Revenue Cycle/HIM regarding whether to appeal RAC decisions, contribute to denial appeals, and share findings with providers.
Review readmissions within 30 days and report findings in case management software.
Identify cost-reduction opportunities, participate in utilization management activities, and refer cases to a Physician Advisor or Medical Director when appropriate.
Participate in performance planning, competency assessment, and individual development planning.
Perform other duties as needed.