Responsible for Care Coordination and Care Transitions Planning throughout the acute care patient experience. This position
works in collaboration with the Physician, Utilization Manager, Medical Social Worker and bedside RN to assure the timely
progression and transition of patients to the appropriate level of care to prevent unnecessary admissions or readmissions. The
Care Management process encompasses communication and facilitates care across the continuum through effective resource
coordination. The goals of this role are to include the achievement of optimal health, access to care, and appropriate
utilization of resources balanced with the patients’ self –determination while coordinating in a timely and integrated fashion.
He/She collaborates with patients, families, physicians, the interdisciplinary team, nursing management, quality, ancillary
services, third party payers and review agencies, claims and finance departments, Medical Directors, and contracted providers
and community resources. If assigned to the Emergency Department, the Care Management process is to address complex
clinical and social situations efficiently in order to avoid unnecessary admissions.
BS in one of following: Nursing or Health related field required or equivalent education/experience. MS in Nursing, Case management, or related field Required or equivalent education/experience.
Licensures and Certifications
CA RN license required. Certified Case Manager (CCM) preferred.
Minimum of three (3) years in acute medical/surgical/ED/critical care nursing area required. Masters of Nursing in Case Management in lieu of three (3) years in acute medical/surgical/ED/ or critical care nursing area may be considered for employment at director’s discretion. Previous Case Management experience preferred. Experience utilizing electronic InterQual or other standardized criteria strongly preferred. .Experience utilizing electronic InterQual or other standardized criteria strongly preferred. Experience with clinical assessment for patient with complex medical, emotional and social needs. Experience using an electronic medical record system Experience and knowledge with MIDAS and Allscripts preferred.
Skills and Knowledge
A broad knowledge base of health care delivery and case management within a managed care environment. Comprehensive knowledge of Utilization Review, levels of care, and observation status. Awareness of healthcare reimbursement systems: HMO, PPO, PPS, CMS, value-based reimbursement models, and alternative payment systems preferred. Working knowledge of laws, regulations, and professional standards affecting case management practice in an integrated delivery system: including but not limited to: CMS, Title 22, CHA Consent Manual, CDPH and TJC. A broad knowledge base of post-acute levels of care and associated regulatory compliance requirements. General understanding of coding and DRG assignment process preferred. Must be able to effectively communicate with, and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners. Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families. Demonstrates commitment to service excellence in all patient, family and employee interactions and in performing all job responsibilities. Functions in a manner to promote quality patient care and assure a positive patient experience. Strong verbal and written communication skills and negotiation skills. Must have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities. Intermediate computer and technology skills. Ability to promote teamwork and to effectively function in teams. Ability to interact effectively with key internal and external constituents using collaboration, and customer service skills that promote excellence in the patient experience.
Employee Status: Regular
Position Status: Non-Exempt
Job Shift: Variable
Shift Hours:8 Hour Shift
Days of the Week Scheduled:Varied Days
Weekend Requirements: Other
Schedule: Per Diem
Hrs Per 2wk Pay Period:Per diem
Applications Accepted:All Applications Accepted