Title: RN Case Manager/Discharge Planner On Call
Location: Roseville, CA
Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the health care team.
Essential Functions:
Utilization Management
- Performs daily preadmission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge.
- Escalates utilization and system problems which have not been resolved at the local level to the next level (RM/UM Director, CCL, DHO, etc.), immediately.
- Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams.
- Educates other health care team members on utilization and cost containment initiatives.
- Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care.
- Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care).
Discharge Planning
- Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient.
- Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other healthcare providers and agencies.
Performance Improvement
- Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols.
- Participates in the development and implementation of guidelines, preprinted physician orders, care paths, etc. for patient care.
- Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum.
- Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, DRGs, LOS, etc.
- Participates in the development, implementation, communication, maintenance and monitoring of local UM Work plan initiatives.
Administrative and Regulatory
- Shares accountability with the UM Manager for planning, developing, and managing the department budget.
- Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff.
- Provides input into the performance evaluations of team members.
- May plan and control work assignments and special projects of team members.
- Assists in developing, implementing and maintaining utilization management policies and procedures.
- Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements (see qualifications).
Qualifications:
Basic Qualifications:
- Experience (usually 2+ years) in direct patient care delivery & management.
- Demonstrated experience in utilization review, case management, & discharge planning preferred (usually 2+ years).
- BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) w/ comparable years of experience required.
- Masters Degree preferred.
- Graduate of accredited school of nursing.
- BLS certification and current California RN licensure required.
- Demonstrated strong communication & customer service skills, problem-solving, critical thinking, & clinical judgment abilities.
- Fundamental word processing & computer navigation skills & the ability to interpret & use analytic data in day to day operations.
- Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA, HIPPA, ERISA, EMTALA & all other applicable federal/state/local laws & regulations.
- Knowledge of healthcare benefits associated w/ various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.).
Preferred Qualifications:
- Knowledge of InterQual. Be assertive in applying and implementing these guidelines.
