RN Case Manager - Patient Care Coordination​/Req

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 medical center system. The case manager assesses 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.

• case management
  • identifies care not meeting acute care criteria, or care that could be provided at an alternate level of care and research, communicates and recommends alternative cost-effective health care services to the health care team.
  • maintains knowledge and understanding of medicare, medi-cal, ccs, ghpp, managed care, and other payer regulations and benefit limits.
  • acts as a resource for physicians and nursing staff regarding discharge planning and all issues that may affect resource utilization and reimbursement.
  • facilitates transitions of patients to the most appropriate level of care by providing pertinent clinical information to other health care providers.
  • works with onsite reviewers to facilitate communication of authorizations and documentation of discharge plans provided by the onsite reviewer.
  • utilizes the hdm and ling systems to trigger and monitor discharge planning and social work needs.
  • serves as a hospital and patient advocate regarding all clinical, social, financial and ethical healthcare matters.
  • identifies and reports abuse of children and adults as mandated by state law.
  • performs other duties as assigned.
• utilization review (ur) management
  • accurately completes admission, concurrent and retrospective reviews of the medical record in the hdm system for medicare, medi‑cal and other payers utilizing interqual criteria for severity of illness and intensity of service criteria.
  • evaluates the medical record for documentation that supports services provided.
  • notifies 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 documentation.
  • utilizes 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 plan.
  • monitors payer authorizations to provide timely concurrent reviews and provides payers with pertinent clinical information for authorization and reimbursement of care.
  • completes appropriate documentation as required by payors, including but not limited to tars and ccs referrals.
  • monitors and develops action plans for metrics including length of stay and resource utilization; uses data to identify trends and problem utilization areas including avoidable days.
  • notifies 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 appropriate.
  • reviews denied claims to evaluate for potential appeal. If appropriate, prepares an appeal including documentation to support care provided and coordinates with the utilization review assistant to assure timely submission of the appeal.
  • provides physician education regarding denied claims to minimize future denials.
• discharge planning
  • responsible for the timely development, implementation and documentation of an individualized discharge plan in collaboration with the patient, their family and the physician.
  • based 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 plan.
  • communicates the discharge plan to the health care team.
  • facilitates use of the most appropriate level of care to conserve patient, hospital and payer resources.
  • obtains authorizations for discharge planning…