Clinical Case Manager (CASE MGR NEX

Job Summary

The Clinical Case Manager facilitates the integration and coordination of major aspects of utilization review and discharge planning for patient needs. This position requires a high level of clinical judgment, problem-solving skills, creativity, organizational and priority setting abilities, with excellent communication skills. Critical aspects of the role involve the assessment of clinical information to determine medical necessity for the identified level of care, assessment for appropriate services needed and resources available, and to facilitate the coordination of both internal and external health care providers to ensure optimal continuity of appropriate and cost effective care.

The Clinical Case Manager must effectively communicate with both internal and external providers and health plans, as well as community resources, to optimize medically necessary services. The Clinical Case Manager demonstrates the ability to fulfill responsibilities through clinical assessment, accurate and sound judgment, application of standardized criteria, and maintaining professional communication. The goal of coordinated discharge planning and utilization is achieved by actively directing and involving members of the multi-disciplinary team, outside providers, community resources, and third-party payors.

The Clinical Case Manager accurately maintains and tracks pertinent data and statistics specific to area of practice, such as delays in service, patients who lack medical necessity for acute hospital admission, denials for continued stays, and other factors affecting appropriate utilization of health system resources.

• Valid California Registered Nurse License without restriction
• Graduation from an accredited school of nursing.
• Minimum of one (1) year recent Case Management experience in discharge planning and/or utilization review management in an acute hospital.
• Licensed RN with current working knowledge of discharge planning, utilization management, performance improvement and managed care reimbursement.
• Knowledge of Medicare, Medi-Cal, and HMO legislation, third party payor contracts, Title XXII, the Joint Commission. Demonstrated knowledge of how these programs/regulations affect the functions and role of the department. Demonstrated ability to incorporate them into departmental systems/processes.
• Knowledge of professional and ethical standards related to Clinical Case Management such as the Nursing Practice Act, the Codes of Ethics from the American Nurses Association and the Standards of Practice & Scope of Services by the American Case Management Association.
• Ability to read and comprehend English text and medical terminology; knowledge of medical and nursing treatment plans, levels of care, and area resources; skill in assessing the appropriateness of medical admissions and continued stay.
• Skill to perform in-depth chart analysis to provide accurate information in a concise, informative manner, identify/analyze problems or issues related to areas of responsibility, developing an appropriate plan, and considering medical needs and resources available.
• Ability to organize and direct varied health care team professionals in a manner that establishes a good rapport and professional working relationship.
• Ability to work efficiently and independently, maintaining a calm manner while under pressure. Ability to organize work to accommodate special projects, deadlines and priorities; ability to be both flexible and adaptable in order to coordinate multiple variables and to respond to the need of a multi-faceted work area.
• Possess clinical skills and knowledge base to assess and refer to discharge planning, possible needs for care necessary to meet patient’s needs on discharge.
• Understands the need to utilize discretion and maintain confidentiality when discussing patient matters.
• Successfully applies interpersonal communication skills in areas such as conflict management.

• Bachelor of Science in Nursing (BSN)

• 30% -…