OVERVIEW OF POSITION:
Responsible for ensuring the continuity of care in both the inpatient and outpatient setting utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. Facilitates continuum of patients’ care utilizing advanced nursing knowledge, experience and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs care management functions on-site or telephonically as the need arises. Reports finding to the Care Management department Supervisor / Manager / Director in a timely manner.
Implements and monitors current medical group care management programs within the policies and procedures set by the Care Management department.
Conducts on-site or telephonic prospective, concurrent and retrospective review of active patient care, including out-of-area and transplant.
Reviews patients’ clinical records of acute inpatient within 24 hours of notification.
Reviews patients’ clinical records within 48 hours of SNF admission.
Reviews patient referrals within the specified care management policy timeframe (Type and Timeline Policy).
Coordinates treatment plans and discharge expectations and discusses DPA and DNR status with attending physician.
Prioritizes patient care needs and meets with patients, patients’ family and caregivers as needed to discuss care and treatment plan.
Identifies and assists with the follow-up of high-risk patients in acute care settings, skilled nursing facilities, custodial and ambulatory settings.
Consults with physician and other team members to ensure that care plan is successfully implemented.
Coordinates provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care.
Communicates authorization or denial of services to appropriate parties. Communication may include patient (or agent), attending/referring physician, facility administration and HCP claims as necessary.
Participates actively in assigned Care Management Committee (CMC) meetings. Documents pertinent patient information, all communication and CMC decisions.
Demonstrates a thorough understanding of the cost consequences resulting from care management decisions through utilization of appropriate reports such as Health Plan Eligibility and Benefits, Division of Responsibility (DOR) and Bed Days.
Ensures appropriate utilization of medical facilities and services within the parameters of the patients’ benefits and/or CMC decisions. This includes appropriate and timely movement of patients through the various levels of care.
Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients and families.
Provides accurate information to patients and families regarding HMO benefits, community resources, referrals and other related issues.
Initiates and oversees data entry into IS systems of all patients within the parameters of care management policies and procedures.
Maintains accurate and complete documentation of care rendered including LOC, CPT code, ICD-9, referral type and date.
Follows patients on ambulatory care management programs, including CHF and home health in order to optimize clinical outcomes.
Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college.
Graduation from an accredited school of Nursing.
California RN license.
Bachelor’s degree in Nursing preferred.
Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross).
Over 3 years and up to and including 5 years of experience.
At least 1 year of recent clinical experience.
3 to 5 years of acute nursing experience in critical care.
Previous care management, utilization review or discharge planning experience.
KNOWLEDGE, SKILLS, ABILITIES:
Ability to type 25 wpm.
Knowledge of current standards of patient care.
Thorough understanding of RN scope of practice.
Manual dexterity to use/handle equipment and instruments.
Ability to effectively communicate and collaborate with physicians, patients, families and ancillary staff.
Ability to make sound, independent judgments and act professionally under pressure.