RN Case Manager

1 month ago

Huntington Park, United States Pipeline Health System, LLC Full time
RN Case Manager - Registered Nurse Per Diem 8-Hour Day Shift

The RN Case Manager (CM) performs a wide variety of tasks and functions. These include utilization review, discharge planning, care coordination and variance management to assure the delivery of necessary services, efficient patient progression, and payment for the services provided.
  • Serves as a liaison between the designated Avanti Hospital and payers to ensure financial coverage for the patient.
  • Coordinates resources and services for the patient/family in response to individual needs and fiscal responsibilities.
  • Works with the multidisciplinary team to ensure coordination of patient care and wise utilization of resources.
  • Documents case management activities in the patient record and in the required information system.
  • The RN CM reports to the Director/Manager of the department.

Essential Job Duties:
  • Applies appropriate clinical knowledge in order to identify patient needs and effectively communicate medical necessity and treatment plan to payers.
  • Reviews concurrently and retrospectively all inpatients for appropriateness of admission, level of care, and length of stay utilizing InterQual criteria.
  • Collaborates with the multidisciplinary team to develop, coordinate, implement and evaluate patient care.
  • Identifies and anticipates discharge needs and collaborates with the multidisciplinary team to ensure that each patient's discharge needs are assessed, planned for, and addressed in a timely manner.
  • Educates and collaborates with the multidisciplinary team including physicians and patients/families regarding utilization issues, documentation of medical necessity, discharge options, and community resources.
  • Anticipates barriers to efficient and effective patient progression by identifying clinical, operational, financial and social issues affecting patient outcomes and intervening to address these issues.
  • Estimates the expected length of stay (ELOS) based on the knowledge of patient cases and interactions with the interdisciplinary team. Communicates expected discharges to the unit charge nurse, patient unit and family.
  • Identifies patients at risk for extended lengths of stay, readmission, and complex discharge needs.
  • Identifies and documents Avoidable Days using the data to address opportunities for improvement.
  • Prevents denials and disputes by communicating with payers and documenting relevant information.
  • Promotes prudent utilization of all resources (fiscal, human, environmental, equipment, and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes.

Licensure/Certifications:
  • Current RN licensed in good standing by the California Board of Nursing
  • Current BLS for Health Care Provider card.
  • Accredited Case Manager (ACM) or Certified Case Manager

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