Job Objective: Under the direction of the Director of Case Management, or designee, the Register Nurse (RN) Case Manager is responsible for prioritizing, planning, and monitoring the patient's progress through the Antelope Valley Medical Center system. The Case Manager assesses appropriate medical care with effective utilization of resources while promoting continuity of care. The RN Case Manager provides guidance and oversight to the LVN Discharge Coordinator, the Discharge Coordinator Assistant and the Utilization Review Assistant.
Duties and Responsibilities:
1. Identifies care not meeting acute care criteria, or care that could be provided at an alternate level of care and research, communicates and recommends alternative cost-effective health care services to the health care team
2. Maintains knowledge and understanding of Medicare, Medi-Cal, CCS, GHPP, Managed Care, and other payer regulations and benefit limits
3. Acts as a resource for physicians and nursing staff regarding discharge planning and all issues that may affect resource utilization and reimbursement
4. Facilitate transitions of patients to the most appropriate level of care by providing pertinent clinical information to other health care providers
5. Works with onsite reviewers to facilitate communication of authorizations and documentation of discharge plans provided by the onsite reviewer
6. Utilizes the HDM and LING systems to trigger and monitor discharge planning and social work needs
7. Serves as a hospital and patient advocate regarding all clinical, social, financial and ethical healthcare matters
8. Identifies and reports abuse of children and adults as mandated by state law
9. Performs other duties as assigned
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Utilization Review (UR) Management
1. Accurately completes admission, concurrent and retrospective reviews of the medical record in the HDM system for Medicare, Medi-Cal and other payers utilizing InterQual criteria for Severity of Illness and Intensity of Service criteria
2. Evaluates the medical record for documentation that supports services provided
3. Notify the physician if documentation does not support the level of care provided and actively works with physicians on the concurrent medical record to improve accuracy and efficiency in capturing pertinent documentation
4. Utilizes the PCC Physician Advisor as needed for intervention with the medical staff relative to medical necessity, utilization of services, clinical documentation, denial review or clarification of discharge plan
5. Monitors payer authorizations to provide timely concurrent reviews and provides payers with pertinent clinical information for authorization and reimbursement of care
6. Completes appropriate documentation as required by payors, including but not limited to TARs and CCS referrals
7. Monitors and develops action plans for metrics including length of stay and resource utilization uses data to identify trends and problem utilization areas including avoidable days
8. Collects and uses data to identify trends and problem utilization areas including avoidable days
9. Identifies drivers of variation of care for high cost, high volume DRGs to assist in focused DRG effort
10. Notifies the physician of potential or actual concurrent denials. Intervenes with the physician, the Physician Advisor and the payer to attempt resolution of denial issues. Consults with the Physician Advisor and department Director and issues letters of non-coverage when appropriate
11. Reviews denied claims to evaluate for potential appeal. If appropriate, prepare an appeal including documentation to support care provided and coordinates with the Utilization Review Assistant to assure timely submission of the appeal
12. Provides physician education regarding denied claims to minimize future denials
13. Refers to the Discharge Coordinator or Social Worker when indicated to facilitate the patient's transition to the appropriate level of care
1. Responsible for the timely development, implementation and documentation of an individualized discharge plan in collaboration with the patient, their family and the physician
2. Based on patient needs, updates the Discharge Plan throughout the hospital stay and maintains accurate, timely documentation on the medical record to enable other members of the Healthcare Team to complete the plan
3. Communicates the Discharge Plan to the health care team
4. Facilitates use of the most appropriate level of care to conserve patient, hospital and payer resources
5. Obtains authorizations for discharge planning needs, and if necessary, negotiate with payers to maximize post-acute care benefits
6. Works with the Discharge Coordinator Assistant to facilitate placement and transfers to other acute and post acute care facilities
7. Works with the Discharge Coordinator Assistant and the nursing unit staff to coordinate medical transportation
8. Assesses for Home Health, Home Infusion and DME needs, makes referrals to the appropriate agencies and documents in the medical record to facilitate the completion of arrangements
9. Develops and maintains knowledge and understanding of hospital and community resources
10. Provides patients with referrals to and education of community resources
11. Collects and uses data to identify trends and utilize discharge planning resources
Non-Essential Duties:
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Assist with other duties as assigned, within skill sets and abilities
Knowledge, Skills and Abilities:
Knowledge
- Working knowledge of Government, State, HMO, PPO, Commercial, and Workers Compensation utilization, authorization and billing guidelines
- Working knowledge of Microsoft Office applications
- Working knowledge of medical terminology
Skills
- Knowledge of basic personal computers
- Proficient in the operation of scanners, copiers, and fax machines
- Good oral and written communication skills
- Good interpersonal skills and customer focus
Abilities
- Ability to manage a heavy caseload in an organized and efficient manner
- Ability to maintain a working relationship with other facilities and departments within the organization
- Ability to document account information at time of account follow-up
- Ability to run case management related reports as needed
AVMC Values: All AVMC employees will effectively demonstrate these values:
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Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
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Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
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Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone. Success is about the whole team.
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Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
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Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
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Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.
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Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.
Education and Experience:
Education
- High School graduate or equivalent
- Bachelor’s degree in nursing, preferred
Experience
- Minimum 3-years broad-based acute care nursing experience
- Case Management, Discharge Planning, and/or Home Health experience, preferred
Required Licensure and/or Certifications:
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Registered Nurse License
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CPR Certification
AVMC Conduct/Compliance Expectations:
- Ability to adhere with AVMC Attendance and Punctuality Policy.
- Ability to adhere with AVMC Leaves of Absence Policy.
- Ability to adhere with AVMC Paid Time Off (PTO) Policy.
- Ability to adhere to the department dress code.
- Ability to organize work and establish priorities.
- Ability to expand on own initiative in performance of duties.
- Skill and ability to follow the telephone etiquette/standards.
- Ability to function effectively under pressure and meet time parameters.
- Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff.
- Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVMC.
- Ability to maintain the confidentiality of patients, hospital and department information.
- Ability to adhere to safety rules and regulations.
- Safely and effectively use all the equipment necessary to carry out duties.
- Ability to interpret and function under hospital and department policies and procedures.
- Conforms with required and appropriate accreditation and regulatory requirements.
- Conforms with and supports hospital quality assurance and improvement guidelines.
- Ability to participate effectively in department and hospital staff education.
- Display a willingness to work as a team player.
- Ability to give and support the highest level of patient/customer satisfaction at all times.
- Supports and adheres to the values and mission statement established by the AVMC Board of Directors.
- Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.
- Ability to follow the Code of Conduct.
Physical Requirements and Working Conditions:
- Primarily works in a climate-controlled area
- Standing and/or walking 75% of the time on duty
- Tolerate repetitive arm and hand movements
A detailed description of the physical requirements of this job is maintained in the Employee Health Department.
NOTE: THE ABOVE STATEMENTS ARE INTENDED TO DESCRIBE THE GENERAL NATURE AND LEVEL OF WORK PERFORMED BY PEOPLE ASSIGNED TO THIS JOB. THIS DOCUMENT IS NOT INTENDED TO BE AN EXHAUSTIVE LIST OF ALL RESPONSIBILITIES, SKILLS, AND WORKING CONDITIONS FOR THE PERSONNEL SO CLASSIFIED.
Education and Experience:
Education
- High School graduate or equivalent
- Bachelor’s degree in nursing, preferred
Experience
- Minimum 3-years broad-based acute care nursing experience
- Case Management, Discharge Planning, and/or Home Health experience, preferred
Required Licensure and/or Certifications:
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Registered Nurse License
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CPR Certification
