Job Description

• Meets with patients within 24 hours of admission and conducts an initial assessment.
• Consults with assigned hospitalisteach day during morning rounds regarding disposition planning and appropriateness for each day of patient’s stay.
• Reviews with hospitalist the patient’s admission and continued stay for medical necessity, appropriateness of care and level of care. Use Milliman and Interqual guidelines as necessary.
• Collaborates with clinical teams and practices to ensure synchronization of sub-areas’ operations to reach organizational and departmental goals. Reviews with hospitalist the patient’s admission and continued stay for medical necessity, appropriateness of care and level of care. Use evidence based review guidelines to conduct utilization review as is appropriate to match the payor
• Investigates, processes and assists with the resolution of provider grievances and appeals in accordance with contractual requirements and corporate policy.
• Begins discharge planning and care assessment within one working day (preferably on day of admission).
• Submits necessary clinical information to the health plan using the accepted format (MIDAS or telephonic) and coordinatehealth plan communication with assigned hospitalist as appropriate.
• For patients who are transitioning to the Skilled Nursing Facilities, refers to nurse practitioner and case manager assigned to the SNF’s for continued review and follow up.
• Authorizes all appropriate services based upon covered benefits and necessity of care provided.
• Coordinatesdischarge planning and alternative treatment plans with PCP/hospitalist/specialist as appropriate.
• Coordinatesthe patient’s care with other health care personnelto ensure that the patient receives care timely post discharge.
• Secures outpatient follow-up appointments and scheduling tests or outpatient procedures with appropriate health care providers.
• Refers to Ambulatory Case Manager patients identified that will need oversight of outpatient care and compliance to avoid unnecessary readmissions.
• Coordinatesreferrals and secure appointment with various CSMNS disease management programs.
• Enters and updates all authorization and clinical information into Nautilus (Access Express) no later than date of discharge.
• Communicates regularly with CSMPN Medical Director, Employee Health Services, Risk Management, and TPA
• Attends all CSMPN clinical team meetings, and report high risk/high cost cases.
• Directstimely and accurate reporting to the TPL carrier of all injured worker cases receiving case management services.
• Ensures appropriate utilization of medical services within the parameters of the workers compensation benefits and/or Utilization decisions. This includes appropriate movement of the patient through the various levels of care.

Qualifications

• Graduation from an accredited school of nursing required
• Bachelor of Science degree in Nursing required

• Valid CA RN license required
• Certified Case Management preferred or willing to obtain within 2 years time from start date
• Current BLS certification from ARC or AHA

• 2 years in acute care nursing - Medical Surgical/Tele/ICU/LTACH or 1 year in acute care nursing (Medical Surgical/Tele/ICU) with 2 or more year of care management experience (UM or DC Planning).
• 1 year of previous experience in case management in the acute inpatient or outpatient settings preferred; knowledge of HMO and Medicare rules in inpatient, home health and at the SNF settings preferred
• Knowledge of workers compensation rules and regulations is highly preferred
• Knowledge of Epic is highly preferred