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Case Manager II-Post Discharge-BU / Integrated Care / SCMG / Full Time / 8-hour Days

Job ID JR122695 Date Posted 07/07/2022
San Diego, California
  • Corporate Offices
  • Day
  • Regular
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Responsibilities

Hours

Shift Start Time:

8:30 AM

Shift End Time:

5 PM

Additional Shift Information:

Variable 8-hour day shift

Weekend Requirements:

No Weekends

On-Call Required:

No


What You Will Do
To provide management of patients transitioning from the inpatient care setting to home. Involves patient assessment and coordination of services in the immediate post discharge phase. Addresses care coordination, facilitation of referrals to providers, vendors, and community services, disease education, caregiver support and self-care counseling. Responsible for evaluation and if necessary modification of patient care plan based on post discharge assessment addressing medical/psychosocial status changes and facilitating the patient/caregiver/family goals to align with patient's new identified problems/barriers and needs. Results in decrease in avoidable readmissions and emergency department visits as well as increased patient and provider satisfaction.

Required Qualifications

  • Education as required for licensure
  • 3 Years Recent hospital experience
  • 3 Years Experience in Case Management/ Utilization Management in Managed Care, preferably in a medical group or HMO setting
  • 2 Years Recent pertinent clinical experience as defined by the CBA
  • California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED


Preferred Qualifications

  • Bachelor's Degree Healthcare


Other Qualification Requirements

  • UM, QM or CM preferred.


Essential Functions

  • Adheres to highest standards of performance by keeping skills and competencies up to date through professional development, identifying gaps in skills and competencies and seeking the knowledge and training necessary to perform at and above standards.
    Keeps current knowledge and understanding of applicable accreditation and regulatory statutes related to health care, managed care, case management practice.
    Maintain individual in-service/performance records.
    Attends and actively participates in department/team process/quality improvement activities.
    Have reliable means of transportation and willing to travel to Doctors offices and Facilities when requested.
  • Applies SCMG criteria for assessing patients in the immediate post discharge phase
    Prioritizes work list based on SCMG policy and procedure.
    Conducts structured assessment to determine patient knowledge base, adherence with the medical care plan and post discharge needs and barriers.
    Assessment information is gathered through multiple sources: telephonic patient/patient designee interview, review of medical records, collaboration with primary care physician, specialists and other health care providers.
    Assessment should include the following components: receipt and understanding of discharge instructions; follow up appointments; medications; DME; home health services; other ancillary services; psychosocial issues and patient compliance.
    Accurate documentation of assessment findings.
  • Coordinates patient care in the immediate post discharge phase
    Demonstrates appropriate and timely maintenance of workload of assigned patients based on SCMG policy & procedure.
    Facilitates communication and coordination of patient care in the immediate post discharge phase among the healthcare providers.
    Collaborates with providers for timely delivery of goods and services by contracted and non-contracted vendors.
    Facilitates implementation/modification of plan of care in collaboration with patient/family, primary care physician, and healthcare providers to maximize quality and cost-effective outcomes and reduce avoidable ED visits and readmissions.
    Problem solves, exploring options to care and determining coverage benefits and alternative plan when necessary to achieve desired outcomes.
    Identifies members for possible case management intervention when there is: lack of established or ineffective treatment plan/specific goals, non-adherence treatment/medications, permanent or temporary alterations in function, medical/psychological/functional complications, lack of resolution in meeting health care needs, lack of education of disease course/process, lack of family/social support, lack of financial resources to meet health care needs and compromised patient safety.
    Educates patient/family, caregiver and healthcare team members about their disease(s), discharge plan, community resources, and insurance benefits
    Accurate documentation of interventions.
    Applies effective interpersonal skills that are age appropriate.
  • Identifies, reports and develops action plan for quality of care issues.
    Demonstrates knowledge of federal, state, county regulatory mandated reporting such as domestic, elder, minor abuse related to physical, financial and psychological well being of our members.
    Assists and works collaboratively with the physician and the SCMG quality department for the monitoring, intervention and documentation of non-adherence to treatment plan.
    Observes the SCMG policy and procedure for reporting and follow up on quality of care issues.
    Collaborates with Physician Network Management, Customer Service and other SCMG departments for process improvement of quality of care.
    Works with providers to address quality issues to maintain and uphold the Sharp HealthCare standards of care.
  • Participates in quality improvement activities related to care and services following the inpatient care continuum.
    Establishes effective working relationships and collaborates with internal and external customers and partners in care.
    Applies effective interpersonal skills that are age appropriate with customers.
    Validates the message by clarifying expectations and verifying understanding of agreement/action plans.
    Uses special needs resources (translation, phone services) to communicate with patients/family, caregiver who speaks another language or have hearing/speech barriers to communication.
    Makes sound decisions and demonstrates ability to handle situations not covered by written or verbal instructions.
    Demonstrates participation in customer service performance improvement projects.


Knowledge, Skills, and Abilities

  • Broad based nursing knowledge in various settings along the health care continuum, including acute, long term acute, sub-acute, skilled inpatient and discharge planning, primary care physician offices, chronic disease management and other nursing and health related specialties.
  • Proficient knowledge and understanding of managed care, utilization management, case management, and healthcare finances.
  • Exceptional communication, customer service, critical thinking, problem solving and computer skills required.
  • Ability to read, speak and hear English clearly.
  • Ability for bilingual communication preferred.
  • Working knowledge of computer programs (Excel, Word).

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

Bachelor's Degree; California Registered Nurse (RN) - CA Board of Registered Nursing
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