SUMMARY: Responsible for coordinating continuum of care and discharge planning activities for a caseload of assigned patients; develops plans of care and discharge plans, monitors all clinical activities, makes recommendations for alternative levels of care, and identifies cost-effective protocols. Care Management provides Care Coordination, Compliance, Transition Coordination, and Utilization Management.
DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.
- Coordinates all utilization review functions, including response to payor requests for concurrent and retrospective review information including Medicare and MediCal regulations/requirements, avoidable days and quality issues. Applies Medical necessity criteria to determine level of care.
- Assures clinical interventions are appropriate for the admitting diagnosis and Level of Care that reflects the standard of care, as defined by the medical staff and the organization; identify inappropriate admit status based on identified criteria and ensures the patient is registered at the appropriate level of care. Utilizes McKesson Interqual clinical guidelines; refers questionable cases to the CM Manager or physician advisor for determination.
- Takes appropriate action when cases do not meet criteria. Escalates to the attending physician and the Care Management physician advisor of any concurrent denials. Prepares case reports; documents treatment plan, progress notes and discharge summary related information as required by Medicare, MediCal, Title 22 and other mandated regulations according to Department standards. Reassesses the patient’s condition when changes occur and revises the care plan when appropriate.
- Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social work, and other healthcare providers and agencies. Completes an initial assessment within 24 hours of admission and documents findings in the electronic health record. Processes referrals and authorizations that adhere to federal, state and local insurance regulatory agencies and offer patient choice per regulation.
- Identifies potential problems and prevents or resolves barriers to the discharge plan, along with the social work team member.
- Mobilizes resources to effect rapid and timely movement of the patient through the system to achieve targeted discharge times established by AHS.
- Identifies and mobilizes patients and family strengths to optimize use of healthcare and community resources. In coordination with patient and family wishes, guides/assists in securing needed post-discharge services.
- Collaborates with Care Management teams (i.e. Care Transition team and CM teams at other facilities) for high-risk patients for timely follow-up appointments and confirms prior to discharge that complex patients are appropriately linked to community services.
- Provides community resource education and coaching, focusing on individual patient self-management principles. 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.
- Communicates with physicians and multidisciplinary health team members to provide continuity of care, supporting and maintaining the multidisciplinary team approach to ensure effective resource utilization and appropriate level of care.
- Makes independent assessments and recommendations regarding course of action in complex situations.
- Confirms all applicable department and regulatory targets for department performance process improvements are attained (e.g., re-admissions, throughput, LOS).
MINIMUM QUALIFICATIONS:
Required Education: Associate Degree in Nursing
Preferred Education: Bachelor’s of Nursing
Preferred Education: Master’s in Nursing
Required Experience: Three years of acute care nursing
Preferred Experience: Medical/surgical or critical care experience; broad clinical background. Within the last 3 years, experience in Case Management in an acute setting or utilization review at a medical group or health plan.
Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California, Active BLS - Basic Life Support Certification issued by the American Heart Association; other advanced life support certifications may be required per unit/department specialty according to patient care policies; CPI - Crisis Prevention Intervention Training (required for all positions at John George Psychiatric Pavilion; and certain positions in the Emergency Department).
Preferred Licenses/Certifications: Certification in Case Management, CCMC or ACM. Bilingual Preferred.
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