1992 - Case Manager II-BU/Utilization Review SGH/Temporary (6 months to 1 Year) Full Time 10 hour shifts
- Grossmont Hospital
Shift Start Time:Variable
Shift End Time:Variable
Additional Shift Information:
Weekend Requirements:As Needed
What You Will Do
The RN CM II assesses, develops, implements, coordinates and monitors a comprehensive plan of care for each patient/family in collaboration with the physician, social worker and all members of the interdisciplinary team in the inpatient and emergency department patient care areas. This position requires the ability to combine clinical/quality considerations with regulatory/financial/utilization review demands to assure patients are receiving care in the appropriate setting and level of care. The position creates a balance between individual clinical needs with the efficient and cost effective utilization of resources while promoting quality outcomes.
- Bachelor's Degree in Nursing or equivalent degree.
- 2 Years Recent pertinent clinical experience as defined by the CBA.
- 3 Years Acute care nursing experience or case management experience.
- 3 Years Case management, utilization review, care coordination experience.
- California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED
- Master's Degree
- Certified Case Manager (CCM) - Commission for Case Manager Certification -PREFERRED
Other Qualification Requirements
- CM certification such as ACM or CCM is an asset.
- Professional development
The RN CM II will:
Actively participates in the performance planning, competency and individual development planning process.
Maintain current knowledge of case management, utilization management, and discharge planning, as specified by Sharp, federal, state, and private insurance guidelines.
- Core principles
The RN CM II will make timely referrals to ensure that the patient is receiving the appropriate care, in the appropriate setting and using the appropriate utilization standards as set by community and professional standard as adopted by the medical staff.
The RN CM II will assure that the patients from all age groups proceed efficiently through the course of hospitalization and beyond through the continuum of care.
The RN CM II will relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following and/or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, collaborate and accept direction.
The RN CM II performs other duties as needed.
- Organizational relationships
The RN CM II will work closely with the healthcare team in reaching unit, facility, and system/network organization goals including reductions in length of stay, decreasing denials, improvement of care transitions, and reduction in avoidable readmissions, improved patient experience, and other quality initiatives.
In the emergency departments, the RN CM II will work collaboratively with other members of the interdisciplinary team to develop relationships and provide pre admission status recommendations for admissions as well as implement a comprehensive, integrated discharge plan from the emergency department(ED) for patients who are being discharged to a lower level of care.
The RN CM II will recommend and document patient classification (status and level of care) for all admissions utilizing established criterion sets.
The RN CM II has accountability for maintaining compliance contractual and regulatory compliance with medical groups as applicable and the hospital.
The RN CM II will have excellent interpersonal skills demonstrated by the ability to work effectively with individuals and or teams across disciplines.
- Care coordination and discharge planning
Within 24 hours of admission the RN CM II will interview each patient/family for anticipated needs post hospitalization. The plan and interventions will be documented in the EMR (e.g., Cerner), and case management software (e.g., Allscripts Care Management).
The RN CM II will develop and document a plan for the day and plan for the stay with patient, family, providers, and nursing staff.
The RN CM II will be responsible for leading the daily care coordination (multidisciplinary) rounds, update the plan, and facilitate necessary coordination of services.
The RN CM II will document and initiate discharge plan including early referrals and authorization for LTAC, SNF, Rehab, homecare, DME and infusion services.
The RN CM II will prepare patient/family for discharge. Document expected discharge date per protocol and arrange discharge pick up appointment with family or significant other.
In collaboration with SW partner, the RN CM II will follow standards for routine patient/family conference.
The RN CM II will ensure effective and safe patient handovers to next level of care; work closely with ambulatory care manager (ACM) at the system level, in clinics, with SCMG and other complex care Case Managers as appropriate, and homecare and sub-acute liaisons.
The RN CM II will support the nursing Model of Care by working closely with nursing managers and staff to achieve Patient and Family Centered Care goals: respect and dignity, information sharing, participation and collaboration.
The RN CM II will facilitate increased volume of cases discharged early in the day to improve capacity management.
The RN CM II will collect and document avoidable day's information in appropriate case management software, e.g., Allscripts Care Management.
The RN CM II will participate in venues to reduce barriers to discharge.
The RN CM II Collaborates with Clinical Resource Coordinators (CRC's/clinical assistants) to assure appropriate referrals for care and services are directed to appropriate network providers, and obtains prior authorization for in network and out of network services as appropriate.
The RN CM II provides timely delivery of regulatory and mandated patient communications and correspondence.
The RN CM II oversees preparation, delivery and documentation of non-coverage letters.
The RN CM II identifies and escalates potential quality variances to management and document per guidelines.
The RN CM II interview all patients with an admission within 30 days to determine what went wrong in the discharge. He/she documents as appropriate in Cerner and Allscripts Care Management and provides information to the department head as indicated.
- Utilization review and utilization management
The RN CM II will:
Conduct initial review at POE or within 24 hours of admission utilizing appropriate care guidelines software. Document findings in CM software, e.g., Allscripts Care Management.
Identify anticipated LOS and document in Allscripts Care Management, communicate to healthcare team.
Conduct daily concurrent reviews per protocol/policy and payer request.
Utilize appropriate care guideline software to identify the correct patient status and level of care.
Work with attending provider to assure correct status, if status and order does not match; works with provider to resolve conflict and document interventions in Allscripts Care Management.
Assure correct documentation is present for 2MN benchmark and presumption.
Assure Medicare Inpatient to observation status changes follow Condition Code 44 requirements.
Actively work observation patient list assuring transitions to next level of Care.
Communicates as indicated with third party payers to obtain necessary authorization for reimbursement of services. Obtain approved days/LOS from provider and communicates this to the care team.
Refer defined cases for medical secondary review and share findings with providers.
Provide advice to Revenue Cycle/HIM regarding RAC decision to appeal, denials, input into appeals, share findings with providers.
Review all cases with readmission within 30 days; report findings in Care Management software such as Allscripts.
Identify opportunities for cost reduction and participate in appropriate utilization management venues.
Escalate and refers cases for consultation with Physician Advisor or Medical Director as appropriate.
Oversee preparation, delivery and documentation of non-coverage letters.
- Leadership, mentorship
The RN CM II will manage multiple assignments effectively; compose written material; organize and prioritize workload; work well under pressure; problem solve; recall information with accuracy; pay close attention to detail; and work independently with minimal supervision.
The RN CM II will identify and appropriately act upon quality variances and will handle complex cases. He/she may be called upon to lead and participate in special projects and assignments.
The RN CM II will be an expert at the use of Allscripts Care Management, MCG, InterQual and other CM software and processes.
Knowledge, Skills, and Abilities
- Advanced PC, data management and analysis skills required (experience with InterQual, and or MCG and Allscripts Care Management an asset).
- An understanding and knowledge of payer eligibility and reimbursement regulations and impact on the continuum of care.
- Knowledge of use of community resources to coordinate safe discharges from acute care and the ED settings.
- Excellent interpersonal skills, as demonstrated by the ability to work effectively with individuals and or teams, and across disciplines.
- Excellent communication and negotiation skills as demonstrated in oral and written forms.
- Ability to work in a collaborative partnership model with Social Workers and other members of the interdisciplinary team, both internal and external. Organizational and time management skills, as evidence by capacity to prioritize multiple tasks.
- Ability to mentor and lead a team.
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class
California Registered Nurse (RN) - CA Board of Registered Nursing; Bachelor's Degree in Nursing; Certified Case Manager (CCM) - Commission for Case Manager Certification; Master's Degree
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