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Case Manager - Out of Network

Job ID: 98259 Date posted: September 24, 2019

  • Sharp HealthCare
  • OON Management
  • Day Job
  • Full-Time

Success Profile

Wondering what qualities it takes to be a successful nursing professional at Sharp? View some of the traits we’re looking for below.

  • Innovative
  • Collaborative
  • Resourceful
  • Advocate
  • Person-Centered
  • Critical Thinker

Responsibilities

Summary
The Out-of-Network (OON) Clinical Case Manager provides timely and appropriate coordination of quality healthcare services in OON facilities to meet an individual’s specific health needs and appropriately repatriates patients into the Sharp Healthcare system and/or contracted network.  The OON Clinical Case Manager 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.
The OON Clinical CM position is a Sharp Systems Services position that reports to the Manager of Sharp Out of Network and Sharp Extended Care.  The Sharp Out of Network Department serves all areas and medical groups for Sharp HealthCare and additional contracted organizations.
Sharp System Services have campuses located in the communities of Kearny Mesa and Serra Mesa and consist of the Spectrum location, the Ruffin Road location and Sharp Operations Center (SOC). These offices provide the centralized integrated system support services to the operating entities within the system. These services include: Strategic Planning, Business Development, Information Technology, Compliance, Internal Audit, Legal, Risk Management and Insurance, Contracts, Human Resources, Facilities Management and Development, Clinical Effectiveness, Finance, Nursing, Systems Supply Chain Services, Marketing and Communications, The Sharp Experience and Sharp University.
Essential Physical Requirements May Include
  • Sitting
  • Keyboarding
  • Mousing
  • Lift up to 10 pounds
  • Push/Pull up to 25 pounds
  • Carry up to 10 pounds
Additional physical requirements of position may be discussed during interview.
Sharp HealthCare is proud to be an Equal Opportunity/Affirmative Action Employer.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, gender identity, transgender status, sexual orientation, protected veteran status or any other protected class.
Keywords:  OON, Out-of-Network, Clinical Case Management, Case Manager, RN, RN Case Management
Location
The position requires travel throughout San Diego and Riverside County Hospitals and community resource agencies along with various Sharp HealthCare offices and medical buildings.
 
Hours
8-hour day shift, 8:00 am - 4:30 pm; weekend rotational coverage, after hours and holidays as needed
Full-time position plus on-call hours
 
Required Skills and Qualifications
  • Current unencumbered California Registered Nurse licensure
  • Current BLS certification for Healthcare Providers
  • Current California Driver’s license
  • Minimum of 3 years of clinical RN experience in the ICU, Trauma, Emergency Room setting
  • Three (3) years of RN acute Care, Ambulatory Care or comparable Case Management Experience
  • Advanced personal computer skills with the ability to navigate between multiple internal and external Electronic Health Records, Data Basses and programs
  • Understanding and knowledge of payer eligibility and reimbursement regulations with impact on the continuum of care
  • Knowledge and ability to use/refer to community resources for coordination of discharge from Acute Care and Emergency Department settings
  • Excellent interpersonal, communication and collaborative skills, as demonstrated by the ability to work effectively with individuals, teams, and across disciplines throughout Sharp HealthCare and multiple external hospital systems
  • Organizational and time management skills as evidenced by capacity to prioritize and reprioritize multiple tasks in a rapidly changing environment
  • Ability to mentor and train Nursing and Clerical staff members
 
Preferred Skills and Qualifications
  • Bachelors of Science Degree in Nursing
  • Master’s degree in Nursing or Health Care related area
  • Current CCM and/or ACM certification
  • Experience with InterQual and/or MCG and Allscripts
  • Bilingual (English/Spanish)

Perks

  • Medical, vision and dental

  • Generous time off

  • Flexible schedule

  • Professional growth

  • Wellness Programs

  • Education reimbursement

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Culture/Values

  • Committed to excellence in all that we do
  • Built to be supportive and educational — a place where employees can grow and thrive
  • A positive, compassionate, friendly and team-oriented atmosphere
  • Thankful for the contributions and hard work of others, and praising their accomplishments
  • Committed to creating a safe environment for those we serve
  • Celebrate diversity, recognizing that our unique differences create a stronger whole

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Sharp HealthCare

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