Monitors the admissions, continued stay, and discharge of patients following pre-­established criteria.   Assures that patients meet InterQual criteria from admission to discharge including appropriateness of level of care.   Conducts interdisciplinary care management rounds.  Ensures collaboration between multidisciplinary healthcare team members, primary physician, community agencies, HMOs/PPOs, CCS, etc., whose services may be required and/or related to the care needs of the patient after hospital discharge.  Monitors nursing and medical plans of care/discharge plans and provides appropriate interventions to assure care is appropriate, coordinated and that avoidable patient days are addressed effectively through education, consultation, and counseling as needed.  Ensure patient centered discharge planning and assessment by communicating the appropriate discharge information and instructions to the primary care giver and primary physician and/or follow-up care agency.   Assures patients are transferred to appropriate approved facilities when required.

This position requires providing service to an ill through rehabilitating neonatal through geriatric patient population in a manner that demonstrates an understanding of the functional/developmental age of the individual served.

This position requires the full understanding and active participation in fulfilling the Mission of San Gabriel Valley Medical Center. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support San Gabriel Valley Medical Center’s strategic plan and the goals and direction of the Performance Improvement Plan (PIP)..

• Discharge planning to occur with patient and family within two working days of admission and relay information to UR Staff.
• Performs admission and continued stay review utilizing criteria approved by the medical staff to ensure that patients meet Severity of illness/intensity of Service criteria.
• Confers with the attending/consulting physician(s) as appropriate when the medical necessity for admission or continued stay in not clear.
• Consults with the Physician Advisor when the admission or continued stay does not meet criteria, care is not being provided timely or does not meet the community standard of care.
• Provides clinical review information to external review entities or insurance companies to ensure authorization for admission and continued stay is obtained.
• Accurately completes the MediCal Treatment Authorization Request (TAR) in detail to ensure payment for hospital services.
• Refers medically complex patients under the age of 65 to the MediCal Case Management program.
• Facilitates transfer of patients to other acute care facilities as required either due to third party payer requirements or county indigent program.
• Identifies potentially avoidable days, delays in service, over utilization or quality of care issues and completes reports as required.
• Performs the Case Management Admission Assessment within two working days of admission.
• With the concurrence of the patient, family and physician develops a plan for post discharge care.
• Refers appropriate patients to Social Services for psychosocial intervention, Advance Directive or end of life education.
• Accurately documents the case management process in the medical record on the Discharge Planning Assessment form N-245.
• Identifies the responsibilities and involvement of the Inter-disciplinary team members in discharge planning activities on an ongoing basis.
• Participates in Interdisciplinary Care rounds/conferences to facilitate coordination of care, goal setting, and developing strategies to facilitate the discharge planning process.
• Communicates the final discharge date and plan with the patient and family to ensure that they are informed as required by law and documents such notification in the Plan section of the Discharge Planning Assessment form (N-245).
• Provides accurate information and completes referrals as appropriate to implement the discharge plan including but not limited to Home Health Services, Hospice, Skilled Nursing Facilities, Durable Medical Supplies, and other community resources.
• Maintain confidentiality as required by HIPPA and only provides information relating to payment, hospital operations or continuity of care.
• Provides “hand off” information to the receiving Case Manager to ensure a safe, smooth transition to other nursing units.
• Refers situations requiring immediate intervention to the Director of Case Management, Risk Management, Director of Quality Management and the Vice President of Medical Affairs.
• Participates in committee meetings, patient care conferences other activities as assigned.
• Participates in department Performance Improvement activities.
• Participates in the orientation of new employees or cross training other case managers as needed.
• Maintains accurate records and statistics of case management activities, as required.
• Demonstrates a continuing effort to improve the quality of case management performance through on-going education.
• Incorporates the core values; dignity, collaboration, justice, stewardship and excellence into daily performance.
• Performs other related duties as assigned or requested. 

Minimum Qualifications

• Graduate of an accredited RN School of Nursing
• Four years recent acute care experience in a critical care setting (preferred)
• Two years Utilization Management/Case Management experience in an acute care setting (preferred)
• Working knowledge of Interqual, Intensity of Service/Severity of Illness criteria.
• Working knowledge of Title XVII and Title XIX.
• Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, and Managed Care is required.
• Ability to negotiate orders with the physicians in order to assign alternate levels of care.
• Working knowledge of community resources.
• Working knowledge of methods to resolve patient needs such as discharge planning, Home Health, DME and SNF’s.
• Ability to case manage smoothly and increase patient/physician satisfaction while staying within guidelines.
• Ability to track outcomes and report findings.
• Able to problem solve effectively.
• Ability to use clinical knowledge to identify potential quality issues, delays in service, post-acute care needs required.
• Must have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, positive personal influence and negotiation skills.
• 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.

Licenses/Certifications

Current California RN License

Current BLS Card

Current MAB Certification (BMC) preferred