Case Manager Utilization RN, PD

Job Summary

Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and continued stays. Makes recommendations to physicians for alternate levels of care when the patient does not meet the medical necessity for inpatient hospitalization. Interacts with the family, patient, and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost‑effective way without compromising quality.

Transfers stable non‑members to planned health‑care facilities. Responsible for complying with AB 1203, post‑stabilization notification, and other duties as described. Must be able to work collaboratively with the multidisciplinary team, multitask and thrive in a fast‑paced environment.

• Plans, develops, assesses, and evaluates care provided to members.
• Collaborates with physicians, members of the multidisciplinary health‑care team, and patients/families in the development, implementation, and documentation of individualized plans of care to ensure continuity, quality, and appropriate resource use.
• Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
• Assesses high‑risk patients in need of post‑hospital care planning.
• Develops and coordinates the implementation of a discharge plan to meet patients’ identified needs; communicates the plan to physicians, patients, families/caregivers, staff, and appropriate community agencies.
• Reviews, monitors, evaluates, and coordinates the patient’s hospital stay to assure that all appropriate and essential services are delivered timely and efficiently.
• Participates in Bed Huddles and carries out recommendations congruent with patient needs.
• Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families.
• Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient, and non‑KFH facilities.
• Acts as a liaison between in‑patient facilities and referral facilities/agencies and provides case management to patients referred.
• Refers patients to community resources to meet post‑hospital needs.
• Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation.
• Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA, and DOL.
• Educates members of the health‑care team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources.
• Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
• Reports any incidence of unusual occurrences related to quality, risk, and/or patient safety as identified during case review or other activities.
• Reviews, analyzes, and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
• Coordinates, participates in, or facilitates care‑planning rounds and patient family conferences as needed.
• Participates in committees, teams, or other work projects/duties as assigned.

• Two (2) years combined RN experience in an acute care setting or case management.

• Completion of an accredited RN training program that allows graduates to take the RN license exam.

• Registered Nurse License (California)
• Basic Life Support

• Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques, and methods of utilization review/management, discharge planning, or case management.
• Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi‑Cal, etc.).
• Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem‑solving skills.
• Demonstrated ability in planning, organizing, conflict resolution, and negotiating skills.
• Computer literacy skills required.

• Bachelor’s degree in nursing or a health‑care related field.
• BSN/MSN and case management experience preferred.
• MS/Telemetry experience preferred.

• Will be required to work on weekends and holidays per Union Contract.