Under the general supervision of the case management director, the case manager RN acts as a patient advocate to hospital clients; Coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost efficient patient outcomes; Looks for opportunities to reduce cost while ensuring the highest quality of care is maintained; Applies Interqual or equivalent severity of illness and intensity of service review criteria to determine medical necessity for admission and continued stay; Provides clinically based case management, discharge planning, and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care. The case manager reviews admissions (observation and inpatient stays) as assigned and determined by case management director or director’s assignee. CM RN reduces financial loss for the organization through the denial management process for all pater types/categories; i.e. Medicare, Managed Care, Medi-cal. Assists with the denial management process by reviewing charts and writing appeal letters. Completes eTAR summaries for Medi-cal eTAR processing. CM RN is a flexible, creative, goal-driven individual who expertly utilizes critical thinking, negotiation, and communication skills. CM RN demonstrates a detailed approach to documentation and information collection.
Works collaboratively with interdisciplinary staff internal and external to the organization. Participates in quality improvement and evaluation processes related to the management of patient care. The case manager is on-site and available seven days a week, as well as holidays and, therefore, is required to work a weekend rotation and an occasional holiday.
Graduate of an accredited school of nursing required
At least one year of RN acute care hospital experience required.
At least one year of working experience within utilization management or case management or comparable healthcare administrative duties
Demonstrated skills in the areas of negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking.
Knowledge and understanding of healthcare financing, community and organizational resources, patient care processes, and data analysis.
Knowledge of post-acute care and community resources.
Computer skills required.
Current RN license in the state of California.