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Out of Network Case Manager / Sharp Corporate / Full Time / Days

Job ID JR126483 Date Posted 07/28/2022
San Diego, California
  • Corporate Offices
  • Day
  • Regular
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Responsibilities

Hours

Shift Start Time:

8 AM

Shift End Time:

4:30 PM

Additional Shift Information:

Weekend Requirements:

Every Other

On-Call Required:

Yes


What You Will Do
The Out of Network (OON) Clinical Case Manager (CM) provides timely and appropriate coordination of quality healthcare services in out of network facilities to meet an individual’s specific health needs and appropriately repatriate patients into the Sharp Healthcare system and/or contracted network. The OON CM 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.

Required Qualifications

  • 3 Years Clinical RN Experience in the ICU, Trauma, Emergency Room setting
  • 3 Years RN Acute Care, Ambulatory Care or comparable Case Management experience.
  • Driver's License - CA Department of Motor Vehicles -REQUIRED
  • California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED
  • AHA Basic Life Support for Healthcare Professional (AHA BLS Healthcare) - American Heart Association -REQUIRED


Preferred Qualifications

  • Bachelor's Degree in Nursing
  • Master's Degree in Nursing
  • Certified Case Manager (CCM) - Commission for Case Manager Certification -PREFERRED
  • Accredited Case Manager (ACM) - American Case Management Association (ACMA) -PREFERRED


Essential Functions

  • Documentation
    The OON CM position is required to be available on call for assigned 24 hour periods that also include weekends and holidays, to facilitate patient repatriations.
    Referrals are responded to promptly with the goal of the department as response within six hours and always, within 24 hours of receipt of information. All information is entered into the OON database and the process for notification of SHC facilities and the Repatriation Physician is followed on every patient. Documentation is timely, appropriate, clear, concise and reflects what is going on in each case as per OON Department Documentation Guidelines.
    The OON CM screens all patients included in case load that have been admitted to the hospital within 24 hours of admission or first working day and documents in OON Data Base by the end of the working day.
    The OON CM will adhere to recording guidelines developed by the OON Department to insure that clinical and utilization management information is clearly and concisely communicated within the OON Data Base that includes current status, plan of care, application of utilization review using appropriate, evidenced based tool (InterQual, MCG and/or health plan criteria) and plan for next review, follow up and repatriation or discharge plan.
    Assessments are performed on an ongoing basis throughout hospitalization through interviews with patient and/or family, in addition to information gathered through rounds, consultation with nursing, physicians, social services, other clinical staff members and the review of the medical record.
    All notes are dated, time and if a late entry, the date and time that the conversation or activity occurred is clearly represented.
    The final disposition of each case is noted in the database before the end of that working day.
    On call requirements are that all pages/phone calls are responded to within 10 minutes of receipt and appropriate action taken.
  • Financial resource
    Has a thorough understanding of SRS and SCMG payer contracts and benefit guidelines. Interprets relevant hospital /3rd party payer/transfer information to the patient/family and OON facility team members. Communicates with admitting physician and repatriation physician regarding patient stay; consults with Medical Director, as necessary, regarding specific patients.
    Identifies reasons for delay in service and or lack of Severity of Illness/Intensity of Service.
  • Professional development
    Actively participates in the performance planning, competency and individual development planning process.
    Maintains current knowledge of case management, utilization management, and discharge planning, as specified by Sharp HealthCare and in accordance with all applicable guidelines. Identifies opportunities for intervention and improvement, which may include analysis of patterns/trends such as: use of inappropriate services, under and over utilization of services/providers, inappropriate level of care and delays in discharge.
    Develops, implements and evaluates educational opportunities/programs for patients/family and staff to promote effective inpatient and post-acute discharge outcomes.
    Participates in data and statistics collection as requested by Utilization Review, Service Line and Quality Improvement Committees.
  • Core principles
    Effectively work with the internal and external hospital teams to repatriate patients to Sharp HealthCare and/or the contracted provider network.
    Insure timely and appropriate referrals are made to support and guide the patient’s care and decision making.
    Work with all involved interdisciplinary teams, physicians and members of the health care team to insure that patients from all age groups are appropriately repatriated to the contracted network and/or proceed efficiently through the course of hospitalization and transition to the next level of care.
    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.
    Perform other duties as needed to support the patient population and organization.
    Maintains confidentiality of all patient, hospital or physician-related information in accordance with policies.
  • Organizational relationships
    Work closely with the healthcare team in reaching system/network organizational goals and metrics that support patient management, discharge planning, care transition and patient satisfaction.
    Work collaboratively with other members of the interdisciplinary team to develop relationships that insure appropriate notification of patients that arrive to the ED and Out of Network Hospitals.
    Effectively work with contracted provider networks and resources that provide for discharge from the ED to appropriate level of care and services.
    The OON CM has accountability for maintaining contractual and regulatory compliance with medical groups, health plans and with network hospitals.
    Have effective interpersonal skills demonstrated by the ability to work effectively with individuals and teams across all disciplines.
  • Care coordination and discharge planning
    Facilitate proactive discharge planning and healthcare services in accordance with payer contracts and benefit guidelines.
    Assists with referrals to community resources.
    Considers the needs and desires of the patient and family when making discharge plans. Facilitates appropriate placement with patient/family, physician, and payer input.
    Ensure effective and safe patient transitions by communicating and providing handoff to all involved Case Management, nursing, physician and multidisciplinary team members using approved tools, methods and guidelines.
    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.
    Collaborates with Clinical Resource Coordinators (CRSs) to assure Coordination and Discharge Planning.
    The OON CM will coordinate with internal and external hospital teams and health plans or designees to provide timely delivery of regulatory and mandated patient communications and correspondence.
    When appropriate initiates and implements appropriate modifications in plan of care. Facilitates streamlining the healthcare delivery process to focus on an effective treatment plan for the patient, including promotion of timely provision of healthcare, effective utilization of resources and transfer of patient into the SHC network.
    Communicates/Collaborates with healthcare team when patient does not meet criteria and identifies cost-effective, appropriate alternatives to acute care.
    Presents potential patients for admission into SHC network and coordinates and communicates pertinent data with admission staff at the SHC entity.
    Identifies and escalates potential quality variances to management and documents per guidelines.


Knowledge, Skills, and Abilities

  • Advanced personal computer skills required with ability to navigate between multiple internal and external Electronic Health Records, Data Bases and programs required, (experience with InterQual, and or MCG and Allscripts an Asset).
  • 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.

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 in Nursing; Master's Degree in Nursing; California Registered Nurse (RN) - CA Board of Registered Nursing; AHA Basic Life Support for Healthcare Professional (AHA BLS Healthcare) - American Heart Association; Certified Case Manager (CCM) - Commission for Case Manager Certification; Accredited Case Manager (ACM) - American Case Management Association (ACMA); Driver's License - CA Department of Motor Vehicles
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