The LVN Case Manager uses Milliman & Robertson and Interqual criteria to evaluate the appropriateness of admissions, concurrent stay and readiness for discharge.  She/he assures correct level of care: critical, telemetry, acute, observation, for all patients.  The Case Manager provides an efficient, coordinated approach to clinical management, with an emphasis on discharge planning, care coordination and utilization management activities for select patient populations across the continuum of programs and services at AHMC.  The essential functions of the LVN Case Manager require constant collaboration with the Social Workers, Nursing staff, Financial Counselors, Medical Staff to coordinate the care of patients in a proactive manner. 

1. Conducts admission reviews and concurrent stays reviews using InterQual on all patients.
2. Assures correct level of care: critical, telemetry, acute, observation, for all admissions. Work with physicians to assign/order appropriate designation and medical record documentation.
3. Coordinated the care of patients in a proactive manner working closely with physicians, nursing staff, and ancillary departments.
4. Conducts discharge planning assessments and coordinates discharge planning needs such as placement in long-term acute care facilities, Skilled Nursing Facilities, DME referrals, and Home Health services as needed.
5. Works with patient or decision on discharge planning options and facilitates discharge planning on a proactive manner.
6. Informs patient or decision maker on Medicare rights and gives IM notices on a proactive manner
7.  Consults with admitting office and patient financial services to assist with Medi-Cal and indigent care applications.
8. Consults additional services to complete a safe and effective discharge plan, including RN Case Manager, Physician, Physical Therapy, Social Services, Palliative care, Interpreters, homeless advocates, Patient Financial Services, behavioral health, etc.
9. Calls clinical reviews to insurance companies and facilitates the approval of days.
10. Communicates approval of days to CBO.
11. Works closely with RN Case Manager to coordinate processes related to denials and appeal process.
12. Identifies high-risk patient through rounding, maintains a list of possible high risk case-types.
13. Develop and maintain community resource information/handouts for patients
14. Coordinates family involvement and decision-making as needed.
15. Participate in Patient Care Rounds and Complex Case Meetings
16. Helps patients obtain a PCP if needed.
17. Follow up as needed with high-risk patients via phone to ensure establishment with PCP, access, prescriptions, payer sources, self-management, etc.
18. Works closely with RN Case Manager to facilitate the care of patients.

            19.   Other duties as assigned.

1. 2 years Utilization Management/Case Management experience preferred in acute care setting.
2. Working knowledge of Milliman & Robertson and Interqual criteria, Intensity of Service/Severity of Illness criteria.
3. Working knowledge of Title XVII and Title XIX.
4. Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, and Managed Care is required.
5. Ability to negotiate orders with the physicians in order to assign alternate levels of care.
6. Working knowledge of community resources.
7. Working knowledge of methods to resolve patient needs such as discharge planning, Home Health, DME and SNF’s.
8. Ability to case manage smoothly and increase patient/physician satisfaction while staying within guidelines.
9. Ability to track outcomes and report findings.
10. Able to problem solve effectively.
11. Ability to use clinical knowledge to identify potential quality issues, delays in service, post-acute care needs required.
12. Must have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, positive personal influence and negotiation skills.
13. Must have strong clinical assessment and critical thinking skills necessary to provide utilization review/discharge planning services appropriate to patients with complex medical, emotional and social needs.
14. Must have the ability to work in a high volume caseload environment and deal effectively with rapidly changing priorities.
15. Excellent computer skills with word, excel and power point.