Job Summary:

As a Registered Nurse/Case Manager, Case Management Unit, you will play a pivotal in a variety of tasks that lead to a high level of customer satisfaction in the most cost-effective manner.  Responsible for Utilization Management, Case Management, and Discharge planning activities on designated units within the Hospital.

Patient Care Coordination: Provide comprehensive patient care and education to patients and families in a supportive and therapeutic environment.

• Communication: Maintain professional communication with colleagues, physicians, and healthcare team members, using the SBAR communication format.
• Confidentiality: Adhere to HIPAA and VPH policies, always maintaining strict confidentiality.
• Cross-training: Cross-train to various areas within the hospital according to policy.
• Documentation: Utilize information technology to document care processes efficiently.
• Care Evaluation: Collaborate with physicians and mentors to evaluate and modify care plans based on patient needs.
• Infection Control: Follow Universal Precautions and VPH infection control standards.
• Medication Administration: Administer medications per hospital policy, reporting any errors promptly.
• Nursing Process: Collect and interpret patient data, formulate nursing diagnoses, and assess patient conditions.
• Patient Advocacy: Advocate for patient and family values, beliefs, and standards.
• Discharge Planning: Provide ongoing discharge education and plan effective discharges from admission.
• Patient Satisfaction: Ensure a caring and compassionate approach, keeping patients and families informed.
• Patient Throughput: Support hospital throughput initiatives for timely patient transfers and discharges.
• Quality Improvement: Participate in unit or hospital quality initiatives and projects.
• Professional Image: Exhibit professionalism in appearance, conduct, and communication. 

Experience:

• Minimum of 2 years' case management experience in an acute setting, with Critical Care experience desirable.
• Previous experience in Case Management, Utilization Management, or Discharge Planning preferred.
• Minimum of 5 years clinical nursing experience is required.

Education:

• Bachelor of Science degree in Nursing is required.

Licensure/Certifications:

• Current licensure with the California Board of Registered Nursing
• Must successfully complete and maintain Management of Assaultive Behavior certification (ex. CPI) at the time of hire or within the first 30 days of employment
• Must successfully complete and maintain LA City Fire Card certification at the time of hire or within the first 30 days of employment 

Specific Responsibilities:

• Chart Reviews:
• Independently performs daily concurrent chart reviews on all assigned patients utilizing approved hospital criteria (Medi-Cal and managed care patients require daily review regardless of criteria recommendation).
• Independently performs timely retrospective chart reviews on all assigned patients utilizing approved hospital criteria.
• Document concurrent TAR reviews daily. Complete retrospective TARs within five (5) business days of notification.
• Document the medical necessity criteria page number and next review date on review records.
• Communication with Managed Care Organizations (MCO) and Medical Groups:
• Proactively call/fax daily concurrent chart reviews to managed care companies (MCO)/medical groups according to payor contract/hospital policy.
• Document the review was called/faxed to MCO/medical group and document the dates approved for continued stay on the review record.
• Ensure MCO/medical group review call-in and approval dates are entered in the Meditech System to avoid payor denials.
• Respond to MCO or medical groups within 24 hours of receiving notice when concurrent or retrospective patient care reviews are requested.
• Performs managed care reviews within 24 hours of notice and TAR reviews within 24 hours of notice.
• Adhere to California Children Services (CCS) care management guidelines when responsible for managing CCS patients. Call/fax timely reviews according to CCS guidelines.
• Refers cases not meeting criteria (including situations involving the timely provision of services) to Physician Advisor or Medical Director as appropriate.
• Obtains authorizations as required by third-party payors for patients whose insurer has such requirements.
• Facilitates transfer of patients to other acute care facilities as required either due to third-party payor requirements or county mandated indigent program.
• Maintains accurate records of all activities relating to the case management/utilization management process.
• Maintains working knowledge of regulations and provider contracts governing coverage of inpatient services, i.e., Medicare, Medi-Cal, California Children Services, Genetically and Handicapped People Program.
• Discharge Planning:
• Performs UR criteria screens all patients and formulates discharge plans within two working days of admission.
• Interviews patients and families to obtain relevant information and develops discharge plan with input from other members of the health care team.
• Provides information and makes referrals as appropriate to implement the plan such as community resources, home health care, institutional placements, financial assistance, equipment needs, and catastrophic case management by third-party payors.
• Refers children in a vegetative state to regional center for placement as needed.
• Identifies situations needing psychosocial intervention and promptly refers them to Social Services.
• Maintains accurate and thorough documentation of discharge planning activities to include those mandated by third-party payors. Records information in the medical record in a timely manner.
• Works collaboratively with the nursing staff/other disciplines to support and achieve the goals of the collaborative care process.
• Confidentiality and Communication:
• Handles all information obtained through the above process with utmost confidentiality.
• Works closely with other members of the health care team to facilitate the above process.
• Maintains objectivity and good interpersonal skills, which allow for effective interaction with a wide variety of people.
• Communicates in a clear, concise manner appropriate to the developmental stage of the patient.
• Demonstrates effective business writing and oral communication skills, handwriting is clear and legible. 

Key Responsibilities:

• Patient Care Excellence: Champion a positive patient experience, ensuring high standards of care and safety.
• Team Leadership: Mentor and support staff, fostering a collaborative and efficient work environment.
• Operational Management: Oversee scheduling, resource availability, and staff assignments to ensure smooth operations.
• Communication & Collaboration: Facilitate clear communication between patients, families, staff, and physicians.
• Performance Improvement: Participate in quality initiatives and ensure compliance with regulatory requirements.

Salary Range: $61.87 to $73.95 per hour