Address
Form of workConcurrently monitors and reviews all member utilizations for medical appropriateness, makes recommendations for alternative levels of care, identifies potential barriers or delays in service, and facilities discharge planning activities.
- Performs the initial inpatient admission medical necessity reviews as well as all ongoing concurrent utilization and quality screening reviews for all, in network, hospitalized patients using industry recognized criteria and guidelines.
- Communicates frequently with the Hospitalist(s) and Specialty provider(s) in order to facilitate timely consultations, solidify the plan of care, clarify the current level of care, and/or problem-solve any potential obstacle to a safe discharge.
- Monitors all physician ordered clinical activities, and when appropriate, makes recommendation for alternative or lower levels of care.
- Anticipates delays in physician decision making which, without immediate intervention, might result in delay(s) of care as well as unnecessarily prolonging a hospitalization.
- When avoidable delays are identified, initiates immediate corrective action(s) including, but not limited to, direct communication with Hospitalist and/or Specialty Provider(s) in an effort to facilitate care.
- Seeks immediate intervention by the Medical Director when unable to impact physician decision-making regarding potential delays in service.
- Gives daily clinical update(s) to team members regarding utilizations including, verbalizing the anticipated next step(s) the Hospitalist(s) or Specialty Provider(s) are likely to pursue as well as what potential obstacle
- Identifies aberrant days resulting from hospital process issues, acquires documentation to support the aberrancy, and reports findings to department Director (or Designee) to ensure DOHC does not incur financial liability for such avoidable delays.
- Accomplishes discharge screening on all admissions, anticipates discharge planning needs, and ensures timely and safe discharges and/or SNF transfers for medically stable patients. When applicable, ensures that all applicable DME and Home Health needs are met.
- Ensures that the Case Management and/or Referral Department receives sufficient supporting documentation so that all requests for post-hospital specialty care can be processed timely, completely and without delay.
- Makes recommendations to the Hospitalist(s) and Specialty Provider(s) regarding discharge planning and dispositions.
- Updates the Daily Hospital Log and reports significant changes in patient’s condition or status, as they occur, to the appropriate department via e-mail including but not limited to: discharge and/or transfer dates, appropriate Case Type, level of care, mode of admission, major procedures performed, consultants utilized, anticipated or actual dispositions, etc.
- Initiates and issues timely denial notifications to the patient or their power of attorney or next of kin, in accordance with both State and Federal regulatory guidelines.
- Identifies and submits to the Quality Improvement Committee any potential or actual quality issues for their review as well as utilization issues; e.g., over/under utilization, delay of service issues, etc.
- Current California RN license.
- Preferably 2 years recent acute hospital experience, including experience with telemetry as well as a broad knowledge of the various nursing disciplines. Prior experience in chart review and analysis required.
- Must possess an extensive understanding of varied diagnostic and invasive procedures and the ability to anticipate care plan changes based on their findings.
- An awareness of Level of Care, Intensity of Service and Severity of Illness criteria, Discharge screens, Skilled Nursing criteria (for SNF) and Home Health criteria.
- Ability to communicate professionally and interface assertively with Physicians.
- Must be detail oriented and able to continually re-prioritize multiple tasks.
- BLS required within 60 days of hire for all RN Case Managers with direct patient care.
BLS is NOT a requirement for RN Case Managers on Hospital Teams. - Current California drivers license and proof of insurance.
