RN Case Manager - Patient Care Coordination/Req Job Lancaster area,California USA,Nursing

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 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

facilitate 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

notify 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

collects and uses data to identify trends and problem utilization areas including avoidable days

identifies drivers of variation of care for high cost, high volume drgs to assist in focused drg effort

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, prepare 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

refers to the discharge coordinator or social worker when indicated to facilitate the patient's transition to the appropriate level of care

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…


Increase/decrease your Search Radius (miles)



Job Posting Language

RN Case Manager - Patient Care Coordination​/Req

RN Case Manager - Patient Care Coordination/Req