RN Case Manager - Patient Care Coordination/Req
Job in
Lancaster, Los Angeles County, California, 93586, USA
Listing for:
Antelope Valley Hospital
Full Time
position
Listed on 2026-01-13
Job specializations:
-
Nursing
Nurse Practitioner, RN Nurse, Clinical Nurse Specialist
Job Description & How to Apply Below
Position: RN Case Manager - Patient Care Coordination - Full Time/Days - Req# 2080666833
job objective
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.
duties
and responsibilities 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 teammaintains knowledge and understanding of medicare, medi-cal, ccs, ghpp, managed care, and other payer regulations and benefit limitsacts as a resource for physicians and nursing staff regarding discharge planning and all issues that may affect resource utilization and reimbursementfacilitate 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) 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 criteriaevaluates the medical record for documentation that supports services providednotify 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, prepare an 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 planning
responsible 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…
To View & Apply for jobs on this site that accept applications from your location or country, tap the button below to make a Search.
(If this job is in fact in your jurisdiction, then you may be using a Proxy or VPN to access this site, and to progress further, you should change your connectivity to another mobile device or PC).
Search for further Jobs Here:
