Job Summary: The Case Manager utilizes clinical expertise, discretion, and independent judgment to apply specialized case and utilization management methodologies and practices to ensure medical appropriateness criteria is met and level of care provided is documented. Serves as a resource to the Collaborative Practice Care Management Team (CPCM) to coordinate care, patient flow, and medically appropriate cost-effective quality healthcare. Identifies high risk financial, clinical, and social cases with potential negative impact and offers CPCM Team solutions and alternatives for care. Negotiates reimbursement with payer sources for unique and complex cases. Utilizes knowledge in the delivery of quality whole person care and interpersonal skills that support excellence in customer service, safe patient care, and professionalism. Contributes to a work environment of caring and cooperation among a culturally diverse workforce and patient population. Performs other duties as needed.
Education and Experience: Bachelor of Science degree in nursing required. Minimum two years of hospital nursing experience required. Minimum two years of case management, utilization review, or discharge planning experience in acute care environment preferred.
Knowledge and Skills: Working knowledge of regulatory requirements and accreditation standards preferred. Able to read, write, and speak with professional quality; use computer and software programs necessary to the position, e.g., Word, Excel, PowerPoint, Access; operate/troubleshoot basic office equipment required for the position. Able to relate and communicate positively, effectively, and professionally with others; provide leadership; be assertive and consistent in following and/or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently with minimum supervision; perform basic math and statistical functions; manage multiple assignments effectively; compose written material; work well under pressure; problem-solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail. Able to distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace; see adequately to read computer screens and written documents necessary to the position.
Licensures and Certifications: Active California Registered Nurse (RN) license required. Basic Life Support (BLS) certification issued by the American Heart Association required. Nationally recognized certification in Utilization Management, Case Management, or Quality preferred (Certification may be in progress or obtained within first two years).
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