In-Patient Nurse Case Manager

Position information

• Job Title: In-Patient Nurse Case Manager
• FLSA Status: Non-Exempt
• Department: Utilization Management
• Reports To: Sr. Manager, Utilization Management

Job summary

Responsible for concurrent review and discharge planning for patients who are hospitalized. The review includes coordination of services for medical necessity, cost effectiveness, timelines of service, and ensuring that quality standards are met.

Performs coordination of services for patients whose health plan has an at-risk agreement to ensure that services are medically necessary, cost effective, provided in a timely manner, and meet local standards of care. Familiar with MCG and Medicare guidelines.

Essential job functions

Research issues utilizing systems and clinical assessment skills, knowledge, and approved procedures in the decision-making process regarding health care services and care provided to members.

Requests and reviews medical records and notes as appropriate; evaluates for medical necessity and appropriate levels of care; collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal, and Imperial Healthcare guidelines.

Performs concurrent review of hospitalized patients and formulates discharge plan/case management within two working days of admission.

Reviews referral requests for ambulatory patients for medical appropriateness based on health plan and other clinical guidelines adopted by Imperial Healthcare.

Refers cases not meeting criteria for medical necessity to the Medical Director during inpatient rounds.

Attends biweekly IDT CM meetings and other meetings as assigned.

Maintains records and statistics as required, including bed days, discharges, re-admissions, and diagnoses.

Performs discharge planning/case management activities

a. Implements discharge plan/case management and makes appropriate referrals to Home Health Agencies, Skilled Nursing Facilities, Board and Care Facilities, Hospice Care, etc. Works closely with discharge planners at appropriate hospitals to facilitate timely transfer or discharge.

b. Arranges placement of patients in facilities that are appropriate for their level of care requirements.

c. Acquires authorization for Skilled Nursing Facilities, durable medical equipment, and home health care when medically necessary and included in the patients’ health plan benefits.

d. Maintains accurate and thorough documentation of discharge planning/case management activities in the patient’s medical records.

Identifies and refers situations needing immediate intervention to the Administrative Director of Managed Care, RN Manager, Medical Director, Quality Assurance, and Risk Management, as appropriate.

Adheres to payroll policies and properly uses the timekeeping system with minimal manual changes.

Maintains regular and consistent attendance.

Adheres to the Compliance Plan and HIPAA regulations.

Marginal job functions

Takes on special projects as needed.

Performs other duties as assigned.

Behavioral expectations

1. Continuous Learning

a. Attends staff meetings as required.

b. Attends appropriate training, seminars, and workshops as required.

2. Customer Focus

a. Maintains client/customer confidentiality and privacy in accordance with HIPAA regulations and IMAS’s Standards of Conduct.

b. Fosters appropriate communication and relations with supervisors, co-workers, and other staff.

3. Quality / Process Improvement / Safety

a. Reports issues of security, health, and/or safety to the appropriate supervisor as soon as practicable.

b. Supports and demonstrates safety throughout all duties performed.

c. Follows established policies and procedures and understands and complies with all regulatory standards set forth by governing entities.

Position requirements

Education / experience

Graduate of an accredited school of nursing.

Minimum of 1 year of case management experience.

Minimum of 1 year of managed care experience.

Hospital inpatient case management or ambulatory case management experience preferred.

Skills / knowledge / ability

Familiarity with Medi-Cal and Medicare guidelines.

Willingness and ability to read, write, speak, and understand English and possess the communication skills necessary to provide accurate information to residents and staff.

Willingness and ability to follow written and verbal directions in English.

Willingness and ability to maintain an appropriate level of confidentiality and privacy.

Willingness and ability to interact professionally with all customers, members, and co-workers, individually and as part of a team.

Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to changing priorities.

Willingness and ability to make appropriate judgments, decisions, and problem-solving determinations in a timely manner and within the context of the situation at hand.

Ability to effectively prioritize items/tasks as required.

Willingness and ability to take initiative and be a self-starter.

Willingness and ability to understand and comply with federal, state, and local regulations.

Licensure / certificate / training

Current California unrestricted RN/LVN license.