Inpatient Case Management Nurse

Signal Hill – based MSO has an immediate opening for a Case Management Nurse position.  The Case Management Nurse will be responsible for providing daily concurrent review of all admissions.  He/she will screens cases for possible case management services according to predetermined criteria.  Authorizes inpatient and/or outpatient treatment according to company's stated criteria.  Evaluate physician's treatment plan and other records to develop a care plan to assist patient to move as rapidly and cost effectively as possible through health care services.  Consults with providers, beneficiaries and family members as needed.  Documents all initial and concurrent reviews, including, but not limited to diagnosis, symptoms, interventions, goals and plan for next review.  Minimum of 2 years of inpatient concurrent reviews, managing Medi-Cal, Commercial and Medicare lives. LVN/RN license is required. Fax resumes to ( 562) 216-5420 or email it to gjenkins@ahcipa.com

 

Job Description

 

Name and Job Title: Case Management Nurse

 

Reports to:  Director, Health Services

 

 Position Summary:

 

The Case Management Nurse will be responsible for providing daily concurrent review of all admissions.  He/she will screens cases for possible case management services according to predetermined criteria.  Authorizes inpatient and/or outpatient treatment according to company's stated criteria.  Evaluate physician's treatment plan and other records to develop a care plan to assist patient to move as rapidly and cost effectively as possible through health care services.  Consults with providers, beneficiaries and family members as needed.  Documents all initial and concurrent reviews, including, but not limited to diagnosis, symptoms, interventions, goals and plan for next review.  Identifies providers for specialized services and negotiate rates when services are provided outside the contracted provider network. 

 

Objective of the Case Management Nurse is to ensure coordination of timely and appropriate care for all hospitalized members; to ensure the delivery of cost efficient, appropriate health care services for all members; To ensure members with complex and chronic care needs are addressed: To ensure plan for coordination among all disciplines; To ensure that medically necessary care is delivered for members that require extensive on-going service; Identification of any potential quality issues.

 Education & Experience requirements:

 

1.  Active RN, LVN, NP or LPN license in good standing in the State of California

2.  Experience in telephonic concurrent review process.

3.  Experience in Case Management in hospital, IPA or managed care environment.

4.  Knowledge of medical criteria for length of stay and/or experience with Healthcare Guidelines.

5.  Basic computer data entry experience.

6.  Knowledge of CPT/ICD-9 codingAccountability / Duties / Responsibilities:

 

1.  Maintain compliance with UM Plan and Care Coordination Policies and Procedures as related to your role of Case Management Nurse.

2.  Coordinate daily concurrent review activity for assigned IPA by coordinating with hospital Case Managers, Health plans, Primary care Physicians, Medical Director, Hospitalists, etc.

3.  Identify estimated length of stay and necessity using established guidelines.

4.  Coordinate and ensure timely discharge planning with appropriate ancillary providers.

5.  Identify potential CCS eligible conditions and coordinate with CCS Coordinator.

6.  Identify cases for outpatient Case Management using criteria and support activities. Coordinate with Link Services, Health Education, etc. to ensure member access to supportive care.

7.  Develop and maintain professional working relationships with Medical Director, facilities, vendors, and all providers within the IPA

8.  Prepare for and present when assigned, case activity at the IPA UM/QM meetings. Ensure follow up activities are completed, including but not limited to obtaining medical records, follow up on cases, appeals of CCS denials, etc.

9.  Report any potential quality issues immediately to IPA Medical Director.

10.  Document clearly and appropriately all case related activity.

11.  Maintain compliance with HIPAA rules and regulations.

12.  Summarize monthly Concurrent Review activity for reporting to IPAs and health plans

13.  Maintain and update logs/books/cheat sheets with ancillary listings, provider rosters, contracts, DORs, etc.

14.  Attend UM Meetings as needed

15.  Maintain current California Nursing license.

16.  Other duties, as assignedReporting, Audits and P&Ps

1.  Develop and submit daily census reports to the Medical Director

2.  Develop and trend monthly BD/K reports, inpatient reports and ESRD, transplant and out of area reports.

3.  Coordinate reports from hospitalists and health plans case managers.

4.  Provide reports and logs to Health Plans in the required format and time frame.

5.  Provide CM reports to the COO and CMOAssist in the development and implementation of Case Management Policies and Procedures