Clinical Care Coordinator

4 weeks ago

Orange, California, United States Prospect Medical Full time

Job Summary

The Inpatient/SNF Case Manager is responsible for coordinating daily Inpatient/SNF services, including assessments, treatment planning, monitoring, evaluation, documentation, and discharge planning. This role interacts with Medical Directors, facility staff, and hospitalists to determine medical necessity of admission, continued stay, or discharge planning needs.

Key Responsibilities

  • Effectively manage patients to ensure the appropriate level of care is provided, utilizing tests and diagnostics in the right facilities to facilitate the highest level of care in the most efficient manner.
  • Communicate effectively with facility staff and hospitalists to gather clinical information and provide timely and accurate responses to requests for information or authorization decisions.
  • Update clinical information in the electronic medical management record system with treatment plans, objectives, results, and next steps.
  • Document all information accurately with approved criteria, utilizing the goal length of stay.
  • Initiate and continue direct communication with healthcare providers involved in patient care, including IPA or Hospitalist Group if applicable, to obtain complete and accurate information.
  • Apply appropriate benefits and utilize current approved criteria along with clinical experience to make authorization decisions.
  • Identify cases not meeting criteria and provide clinical information and rationale to the Medical Director for review and determination.
  • Participate in daily rounds with current and accurate clinical information.

Requirements

  • Three to five (3-5) years' experience in a Medical Group or Health Plan setting with strong clinical skills and critical thinking.
  • Four (4) years of experience in a managed care setting.
  • Experience with Microsoft Office Word required.
  • Recommend but not required, knowledge of NCQA, Medicare, Health Plan, DHS, and State standards and other regulatory requirements.
  • Maintain strong working relations with internal and external customers.
  • Effectively articulate clinical and non-clinical information to persons of all levels.
  • Communicate positively and effectively.
  • Maintain member confidence and protect operations by keeping claim information confidential in compliance with HIPAA.

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