RN Case Manager - Patient Care Coordination
Job in
Lancaster, Los Angeles County, California, 93586, USA
Listing for:
Antelope Valley Hospital
Full Time
position
Listed on 2026-02-27
Job specializations:
Salary/Wage Range or Industry Benchmark: 60000 - 80000 USD Yearly
USD
60000.00
80000.00
YEAR
Job Description & How to Apply Below
Position: RN Case Manager - Patient Care Coordination - Full Time/Days - Req#1996807369
Job Objective
: Under the direction of the Director of Case Management, or designee, the Register Nurse (RN) Case Manager is responsible for prioritizing, planning, and monitoring the patient's progress through the Antelope Valley Hospital system. The Case Manager assesses for appropriate medical care with effective utilization of resources while promoting continuity of care. The RN Case Manager provides guidance and oversight to the LVN Discharge Coordinator, the Discharge Coordinator Assistant and the Utilization Review Assistant.
Duties and Responsibilities:
Case ManagementIdentifies care not meeting acute care criteria, or care that could be provided at an alternate level of care and researches, communicates and recommends alternative cost effective health care services to the health care teamMaintains knowledge and understanding of Medicare, Medi-Cal, CCS, GHPP, Managed Care, and other payer regulations and benefit limitsActs as a resource to physicians and nursing staff regarding discharge planning and all issues that may affect resource utilization and reimbursementFacilitates transitions of patients to the most appropriate level of care by providing pertinent clinical information to other health care providersWorks with onsite reviewers to facilitate communication of authorizations and documentation of discharge plans provided by the onsite reviewerUtilizes the HDM and LING systems to trigger and monitor discharge planning and social work needsServes as a hospital and patient advocate regarding all clinical, social, financial and ethical healthcare mattersIdentifies and reports abuse of children and adults as mandated by state lawPerforms other duties as assignedUtilization Review (UR) ManagementAccurately completes admission, concurrent and retrospective reviews of the medical record in the HDM system for Medicare, Medi-Cal and other payers utilizing Inter Qual criteria for Severity of Illness and Intensity of Service criteriaEvaluates the medical record for documentation that supports services providedNotifies the physician if documentation does not support the level of care provided and actively works with physicians on the concurrent medical record to improve accuracy and efficiency in capturing pertinent documentationUtilizes the PCC Physician Advisor as needed for intervention with the medical staff relative to medical necessity, utilization of services, clinical documentation, denial review or clarification of discharge planMonitors payer authorizations to provide timely concurrent reviews and provides payers with pertinent clinical information for authorization and reimbursement of careCompletes appropriate documentation as required by payors, including but not limited to TARs and CCS referralsMonitors and develops action plans for metrics including length of stay and resource utilization uses data to identify trends and problem utilization areas including avoidable daysCollects and uses data to identify trends and problem utilization areas including avoidable daysIdentifies drivers of variation of care for high cost, high volume DRGs to assist in focused DRG effortNotifies the physician of potential or actual concurrent denials. Intervenes with the physician, the Physician Advisor and the payer to attempt resolution of denial issues. Consults with the Physician Advisor and department Director and issues letters of non-coverage when appropriateReviews denied claims to evaluate for potential appeal. If appropriate, prepares appeal including documentation to support care provided and coordinates with the Utilization Review Assistant to assure timely submission of the appealProvides physician education regarding denied claims to minimize future denialsRefers to the Discharge Coordinator or Social Worker when indicated to facilitate the patient's transition to the appropriate level of careDischarge PlanningResponsible for the timely development, implementation and documentation of an individualized discharge plan in collaboration with the patient, their family and the physicianBased on patient needs, updates the Discharge Plan throughout the hospital stay and maintains accurate, timely documentation on the medical record to enable other members of the Healthcare Team to complete the planCommunicates the Discharge Plan to the health care teamFacilitates use of the most appropriate level of care to conserve patient, hospital and payer resourcesObtains authorizations for discharge planning needs, and if necessary, negotiates with payer to maximize post acute care benefitsWorks with the Discharge Coordinator Assistant to facilitate placement and transfers to other acute and post acute care facilitiesWorks with the Discharge Coordinator Assistant and the nursing unit staff to coordinate medical transportationAssesses for Home Health, Home Infusion and DME needs, makes referrals to the appropriate agencies and documents in the medical record to facilitate the completion of arrangementsDevelops and…
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