The RN Case Manager is responsible for performing a high- level clinical assessment and reassessment of acute care Inpatients for the purpose of performing utilization review, resource management and safe discharge planning. The RN Case Manager prioritizes, plans, organizes, and implements timeliness of care. Collaborates with the interdisciplinary healthcare team to promote and coordinate the delivery of safe and cost-effective patient care, transition of care and discharge planning. The RN Case Manager advocates for patient self-determination and choice. Practices clinical competence in evaluations and planning with awareness and respect for patient and family diversity. Monitors and coordinates resource utilization throughout the continuum of care and evaluates timeliness of services. Performs admission, continued stay and discharge review utilizing medical staff-approved decision support criteria. Ensures case management documentation in the medical record is clear and complete.
Collaborates as needed with the patient and family to optimize client outcomes. May include work with community, local and state resources, primary care provider, and members of the health care team, payer, and other relevant health care stakeholders to facilitate appropriate patient transfers, discharges and transitions of care. Identifies timely and effective alternative lower level of care settings for patient care in accordance with the patient’s medical necessity, stability, the patients’ preferences and health plan benefits. Identifies timely post-hospital nursing care needs and arranges for services as appropriate. Provides patient and family appropriate resources and/or referrals. Makes timely and appropriate referrals to, and seeks consultation with others when needed, the patient-centered provision of services; such as Social Services (i.e., Durable Power of Attorney).
Applies medical necessity per (InterQual guidelines and/or other hospital approved utilization review criteria) to determine appropriate level of care and length of stay. Ensures utilization review is completed and documented concurrently, and provided to the patient’s payer as required. Ensures timely escalation of unresolved care coordination issues to the appropriate level. Enters delays in service and avoidable days regarding exceeded payer LOS variances. Communicates denials and physician related utilization management practices to immediate supervisor same day as identified.
Collaborates with patients/caregivers to set goals consistent with physician treatment plans, and patient resources and choices. Collaborates with the multidisciplinary team for timely discharge planning assessments and reassessments and documents concurrently in the patient's medical record in compliance with hospital policy and all regulatory agencies. Provides appropriate instructions to discharge care coordinators as needed.
Acts as an effective liaison to medical staff to ensure continuity and congruity of hospital services in accordance with the patient’s plan of care.
Participates in-patient and family meetings; respecting and promoting patient choice and documents informed decision making. Utilizes knowledge of psycho-social and physical factors that affect functional status on discharge.
Contributes requested data for the Utilization Management Committee.
Minimum Education: Graduate from an Accredited Professional School of Nursing required. Bachelor of Science in Nursing preferred.
Minimum Experience: One (1) year of acute hospital case management experience OR successful completion of Alta Nursing to Case Management Training Program required. Computer/EMR Proficiency and Literacy required. Knowledge of CMS, Medicare, Medi-Cal and Managed Care reimbursement required. Familiarity of Joint Commission, CMS, CDPH requirements required. Excellent written and verbal communication skills in English. Ability to establish and maintain effective working relationships across the organization. Ability to facilitate and lead interdisciplinary rounds. Bilingual skills to communicate effectively with patients and families preferred. Familiarity with AllScripts Care Management preferred. Proficiency with Milliman Care Guidelines or Interqual preferred.
Req. Certification/Licensure: Current Licensure as a Registered Nurse in the State of California required. Certified Case Manager (CCM) preferred.
Employee Value Proposition
Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:
Medical, dental, vision insurance
How to Apply
To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!
We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.