Case Manager-OON-Out of Network Management-System Services-Remote-Full Time-Eves
2 weeks ago
:
Shift Start Time:
11:
30 AM
Shift End Time:
8 PM
AWS Hours Requirement:
8/40 - 8 Hour Shift
Additional Shift Information:
8-hour day shift with weekend coverage as needed, currently every 6th weekend
Weekend Requirements:
As Needed
On-Call Required:
Yes
Hourly Pay Range (Minimum - Midpoint - Maximum):
$ $ $90.668
The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.
The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.
What You Will DoThe 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 Qualifications3 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
California Registered Nurse (RN) - CA Board of Registered Nursing
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 resourceHas 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.
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
AHA Basic Life Support for Healthcare Professional (AHA BLS Healthcare) - American Heart Association; Driver's License - CA Department of Motor Vehicles; Master's Degree in Nursing; Accredited Case Manager (ACM) - American Case Management Association (ACMA); Bachelor's Degree in Nursing; California Registered Nurse (RN) - CA Board of Registered Nursing; Certified Case Manager (CCM) - Commission for Case Manager Certification
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