Access Case Manager

The Acess Case Manager is responsible for utilization review, utilization management, and quality assurance activities for assigned ares of responsibility within the Cottage Health System. Additionally, the case manager will champion, engage, manage and monitor proactive communications and interventions by and between relevant stakeholders with regard to care management. Case management will work collaboratively and proactively with the medical staff, nursing staff and other disciplines to support and achieve the goals of the collaborative care process.

Case managers will maintain a working knowledge of regulations and provider contracts governing coverage of inpatient services (i.e., Medicare, Medi-Cal, California Children Services, Genetically Handicapped People Program, Contracted Medical Groups). They will maintain and model interpersonal skills and productive relationships that allow for and support effective interaction with a wide variety of stakeholders. Case managers will consistently demonstrate professionalism and compassion with regard to human dignity, preserving and protecting client autonomy and rights and with respect for patient/family values and beliefs.

Case management activities will result in quality outcomes, optimal care/cost management of services and/or procedures, a high level of customer satisfaction, and contribution to an overall value-oriented experience of stakeholders and persons served.

This is not an exhaustive statement of duties, responsibilities, or requirements. Employees will be required to perform any job, with related instruction given by their supervisor, subject to reasonable accommodation.

* Independently engages and manages pre-transfer screening for all inquiries Ensures compliance with EMTALA guidelines Applies Inter Qual criteria/guidelines for severity of illness and intensity of service to ensure appropriateness of admissions/higher level of care needs Discusses and reviews inquiries with appropriate stakeholders prior to acceptance to best align care management planning, appropriate level of care, CHS available resources and funding resources.

Coordinates timely, service-oriented communication between all relevant stakeholders:
Sending facility Referring physician Receiving physician Receiving service line area Assures appropriate transportation is orchestrated that will best meet the needs of the patient served Facilitates hand-off to receiving service line area ? including as appropriate, taking initial orders from the receiving physician Validates patient?s classification/accommodation prior to admission [inpatient vs. observation] Maintains timely and accurate records for transfer management activities Acts as transfer resource as needed for all CHS campuses (40%)

* Acts as the resource case manager for the Emergency Department Performs pre-admission review on all elective and scheduled patients, as well as all patients admitted through emergency services applying Inter Qual criteria guidelines to ensure for appropriate severity of illness and intensity of service:
To validate appropriateness of the admission, To support the provider in determining the appropriate status of the admission (observation vs. inpatient). When admission is not appropriate, acting as resource to provider and patient for counsel, education and referral for access to the most appropriate level of care Acts as liaison between CHS and the county/county programs as appropriate for admission management, referral and/or resource Manages basic UR/UM/DCP functions as appropriate Maintains timely and accurate documentation for all case management activities as appropriate (40%)

* Understands the principles of reimbursement as well as processes and procedures for securing authorization and continued funding from payers Ascertains healthcare benefits utilizing both internal and external resources as appropriate to coordinate necessary and appropriate care, while appropriately preserving the healthcare benefits of the beneficiary Ensures approved Treatment Authorization

Requisition s (TAR?s) from physician offices are received for pre-admissions Identifies and refers…