Summary
SUMMARY:Responsible for coordinating continuum of care and discharge planning activities for a caseload of assigned patients; develops plans of care and discharge plans, monitors all clinical activities, makes recommendations for alternative levels of care, and identifies cost-effective protocols. Care Management provides Care Coordination, Compliance, Transition Coordination, and Utilization Management.
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1. Coordinates all utilization review functions, including response to payor requests for concurrent and retrospective review information including Medicare and MediCal regulations/requirements, avoidable days and quality issues. Applies Medical necessity criteria to determine level of care.
4. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social work, and other healthcare providers and agencies. Completes an initial assessment within 24 hours of admission and documents findings in the electronic health record. Processes referrals and authorizations that adhere to federal, state and local insurance regulatory agencies and offer patient choice per regulation.
5. Identifies potential problems prevents and or resolves barriers to the discharge plan. Along with the social work team member
7. Identifies and mobilizes patients and family strengths to optimize use of healthcare and community resources. In coordination with patient and family wishes, guide/assist in securing needed post discharge services
8. Collaborates with Care Management teams (i.e. Care Transition team and CM teams at other facilities) for high risk patients for timely follow-up appointments and confirms prior to discharge that complex patients are appropriately linked to community services.
9. Provides community resource education and coaching, focusing on individual patient self-management principles. Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient.
Communicates with physicians and multidisciplinary health team members to provide continuity of care, supporting and maintaining the multidisciplinary team approach to ensure effective resource utilization and appropriate level of care.
Makes independent assessments and recommendations regarding course of action in complex situations.
Confirm all applicable department and regulatory targets for department performance process improvements are attained (e.g., re admissions, throughput, LOS).
MINIMUM QUALIFICATIONS:
Required Education:Associate Degree in Nursing
Preferred Education:Bachelor’s of Nursing
Preferred Education:Master’s in Nursing
Required Experience:Three years of acute care nursing
Preferred Experience:Medical/surgical or critical care experience; broad clinical background. Within the last 3 years, experience in Case Management in an acute setting or utilization review at a medical group or health plan.
Preferred Licenses/Certifications:Certification in Case Management, CCMC or ACM. Bilingual Preferred.
