Website College Medical Center
This position supports the Mission of the Hospital through the provision of distinctive and compassionate care to our patients. This position is responsible for utilization review, assessment of discharge planning needs and coordination of effective discharge plan.
- Current CA Nursing License RN/LVN
- Current CPR BLS for healthcare provider’s card upon hire
- Two years previous clinical experience in acute care setting. Minimum one year experience as case manager in acute care setting.
- Demonstrate the knowledge and skills necessary in Case Management with an understanding of severity of illness and intensity service.
- Ability to demonstrate knowledge and skills necessary to provide care appropriate to the age served on the unit. Possess knowledge of growth and development over the life span.
- Must be able to speak, read and write in English.
Moderate walking/standing. Lifts, positions, pushes and /or transfers patients less than 20 lbs. Some reaching, stooping, bending, kneeing and crouching. Hand manipulation, both fine and gross dexterity are required for writing and technical skills.
Frequent exposure to noise, cold and heat. Occasional exposure to bloodborne pathogens, chemicals, general cleaning chemicals.
MAJOR TASKS, DUTIES AND RESPONSIBILITIES
(All duties listed below are essential to the job.)
* General Staff Accountabilities
- Employee’s conduct conforms to the Mission, Vision, Values, and Code of Conduct of College Medical Center.
- Values individual differences and demonstrates sensitivity to the cultural needs of others.
- Respects the rights, privacy and property of others, and maintains strict confidentiality.
- Effectively protects all health information from unauthorized access per HIPAA regulations and all applicable local and state laws.
- Exhibits good attendance and punctuality.
- Provides appropriate notice prior to vacation/time off and notifies supervisor a minimum of two hours prior to shift when unable to come to work.
- Observes allotted break and meal periods as prescribed by Hospital Policy and follows time card procedures by accurately writing in and out.
- Attends to personal affairs to avoid any interference with productivity.
- Adheres to the Dress Code.
- Demonstrates an understanding of their personal role in the case of fire/disaster and participates in Performance Improvement activities.
- Functions with an awareness of patient safety issues and applies basic principles of safety as identified within the facility.
- Follows the occurrence reporting policy and procedure in reporting any potential safety issues.
* Job Specific Accountabilities
Demonstrates effective clinical skills in assessment of medical necessity for observation and inpatient encounters
- Performs Initial UR within first business day of encounter and concurrent reviews to assess for medical necessity for hospitalization and continued stay utilizing Interqual Criteria (IC). Refers cases not meeting IC for observation. Inpatient encounter or continued stay to the Physician Advisor (PA) for review. Documents intial and concurrent reviews on review worksheets for Medicare, HMO/PPO and self pay cases and on TARS for Medi-cal cases.
- Provides Initial and concurrent reviews to health plans or designated IPA (written or verbal as requested by health pla/IPA). Documents authorization or denial provided by health plan or IPA for hospital encounter in Cerner APPS. Notifies attending physician immediately if acute care encounter is denied.
- Informs attending physician of any limitations of health insurance benefit coverage for hospital care(i.e emergent care codes for Medi-cal benefits, any exhausted benefit issues, lack of medical insurance) and facilitates notification of financial counselor for their follow up.
- Identifies charts that have insufficient documentation, treatment plan and/or medical necessity to justify admission or continued stay and communicates with attending physician and/or consultant.
Demonstrates effective clinical skills in assessment of discharge planning needs and coordination of appropriate discharge plan
- Assesses discharge planning needs with intial review in collaboration with patients, their family or support systems, physicians and other multidisciplinary team members and coordinates patient’s discharge planning needs.
- Identify patients at risk for re-admissions and establish effective discharge plan that includes coordination of community resources such as In Home Supportive services (IHSS), meals on wheels, community van transportation services, referrals to area/cOunty clinics and scheduling follow-up appointments with primary care physicians as indicated.
- AS part of coordination of discharge planning needs, facilitates referrals to other acute care,long term care facilities, community resources, home health agencies (HHA) and durable medical equipment (DME) vendors with appropriate documentation entered in electronic medical record( EMR). Utilizes contracted acute care facilities, skilled nursing facilities (SNF), HHA”S and DME vendors as required by delegated health plan or IPA.
- Provides patients/families written resource information on Medicare Certified SNF’s and HHA’s when the plan is for SNF placement or home with home health. Works closely with the patient and family to coordinate referral to facility or agency of patient’s preferred choice.
- Contacts Social Worker at time of initial and/or concurrent review when concerns identified regarding patient’s psychosocial or community resource linkage needs, financial issues that could impact that could impact continuum of cae on discharge, or identified reportable adult/elder/child abuse.
- Actively participate in multidisciplinary team rounds and collaborate with other disciplines to affect an appropriate discharge plan.
Demonstrates effective clinical assessment skills to identify any quality of care issues and to report to Quality Management
- Indentifies any delays in services ordered by physician and communicates with appropriate departments or providers to help ensure patient receives services ordered timely at that point.
- Identifies any quality of care concerns including but not limited to post-surgical complications.
- Generates Notification/Occurrence Reporting Form and provides to Manager of Case Management for review and signature. Send completed Notification/Occuirence Reporting Form to Quality Management Department.
Demonstrates ability to provide education to healthcare providers regarding role of Case Management
- Identifies education needs and provides instruction on identified needs in an effective manner.
- Participate in new employee orientation as requested.
- Educates hospital staff, physicians, and house staff in the Case Management process.
Demonstrates dedication to meeting the expectations of external costumers
Acts appropriately as a liaison between QIO and this hospital in preparing charts for any QIO audit as requested.
- Maintains working relationship with all outside review organization..
- Maintains and utilizes a Community Resource Book for discharge planning which includes facilities, outreach programs, and special interest for our patients.
Maintains Necessary licensing, certification and knowledge while attending all required classes
Follows established policies and procedures to include dress code, attendance, punctuality and personal conduct
Consistently contributes to the team effort
* Customer Service
- Exhibits behavior that is courteous, compassionate, polite, friendly, and respectful towards patients, visitors, physicians, and co-workers and extends self to make patients, visitors, clinical staff, and peers feel welcome and respected.