JOB RESPONSIBILITIES:
- Provide on-site (hospital, skilled nursing facility) and/or telephonic inpatient case management and concurrent review for identified hospitalized members.
- Monitor medical necessity, appropriateness and efficiency of care using established inpatient guidelines, contacting Supervisor, Physician, Specialist, Hospitalist, and Medical Director as needed.
- Coordinating and assisting with discharging patients from hospitals and SNFs.
- Coordinating transfer of patient to in network facilities when appropriate.
- Participate in discussion of delays / barriers / progression of care at care coordination rounds or in 1:1 meetings with physicians, specialists and/or hospital staff.
- Be knowledgeable of patient’s available benefits / coverage / payor information.
- Be knowledgeable of community programs and resources available to patients within their benefit plan.
- Prioritize daily workload to ensure efficiency in completing daily work (patient discharge needs are met, guidelines are followed with proactive discussion of delays / barriers to efficient care, data entry is completed).
- Facilitate communication between patient, family, physician, social services, and vendors to maintain continuity of care and appropriate use of resources.
- Serve as a resource to patients, providers, and internal departments. Facilitate and comply with application of benefits processes as needed in close coordination with medical director and care team. Perform utilization management for HealthPartners members admitted to Out of Network Facilities, acute rehabilitation facilities, facilitating the approval/denial of services provided.
- Assist in monitoring of annual financial goals for inpatient case management LOS, readmission’s, and denial rates, cost savings, patient/provider satisfaction and achievement of outcomes.
- Remain current with knowledge and skills of case management and utilization management practices, application of guidelines, policies and procedures related to case management.
- Remain current with knowledge to ensure compliance with government programs such as Medicare / Medicaid requirements and regulations.
- Discuss cases not meeting medical criteria and cases with utilization issues with physician, social worker, other care team members and medical director as needed.
- Assist in monitoring of annual goals for case management LOS, referrals, readmissions, denial rates, cost savings, patient/provider satisfaction and achievement of outcomes.
- Serve as a liaison to other agencies, departments, or community resources as needed to coordinate care in transition planning.
- Participate in required educational programs and actively demonstrate self-directed learning and continuing education to enhance professional development in the area of case management.
- Participate in staff development activities and staff meetings.
- Identify and refer to manager and supervisor all cases involving complex medical issues for review.
- Record, monitor and report data such as clinical outcomes achieved, potentially avoidable and medically necessary variances, denials, length of stay, reviews completed and outcomes (savings and referrals), and discharge dispositions on a daily basis.
- Work with the attending physician, hospitalists/rounders, specialists, hospital and social work staff to create an actionable plan of care and transition / discharge plan for each patient followed, as needed.
- Demonstrate knowledge regarding transition criteria and level of care and use of appropriate community-based resources.
- Review and assesses inpatient cases for eligibility, benefits and limits, medical necessity and ongoing appropriate level of care.
- Function independently and as part of a team, working effectively with various departments, internal and external staff, facilities, patients, patients’ family, and physicians to facilitate quality and efficient patient care.
- Perform other duties as assigned.
REQUIRED QUALIFICATIONS:
· RN/LVN with current unrestricted license in the State of California.
· Two years experience working with a medical group or IPA preferred.
· Completion of case management certificate preferred.
· Valid CA driver's license, current DMV printout and insurance required.
· Must meet hospital credentialing requirements to obtain facility ID.
· Excellent verbal, written and interpersonal skills
Job Type: Full-time
Job Type: Full-time
Pay: $30.00 - $35.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Education:
Experience:
- Nursing: 1 year (Preferred)
- Case management: 1 year (Preferred)
License/Certification:
Willingness to travel:
Work Location: In person
