Care Manager, Registered Nurse

The goals of this role are to include the achievement of optimal health, access to care, and appropriate utilization of resources balanced with the patients' self –determination while coordinating in a timely and integrated fashion. He/She collaborates with patients, families, physicians, the interdisciplinary team, nursing management, quality, ancillary services, third party payers and review agencies, claims and finance departments, Medical Directors, and contracted providers and community resources. If assigned to the Emergency Department, the Care Management process is to address complex clinical and social situations efficiently in order to avoid unnecessary admissions.\n\n**Job Description**:\n\n**

Education

**\n- Graduate of an accredited school of nursing\n\n**CERTIFICATION &

Licensure

**\n- RN-Registered Nurse of California Upon Hire\n\n**TYPICAL

Experience

**\n- 2 years of experience in acute care case management or health plan case management/utilization management.\n\n**SKILLS AND KNOWLEDGE:**\n- A broad knowledge base of health care delivery and case management within a managed care environment.\n- Comprehensive knowledge of Utilization Review, levels of care, and observation status.\n- Awareness of healthcare reimbursement systems: HMO, PPO, PPS, CMS, value-based reimbursement models, and alternative payment systems preferred.\n- Working knowledge of laws, regulations, and professional standards affecting case management practice in an integrated delivery system: including but not limited to: CMS, Title 22, CHA Consent Manual, CDPH and TJC.\n- A broad knowledge base of post-acute levels of care and associated regulatory compliance requirements.\n- General understanding of coding and DRG assignment process preferred.\n- Must be able to effectively communicate with, and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners.\n- Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.\n- Demonstrates commitment to service excellence in all patients, family and employee interactions and in performing all job responsibilities.\n- Functions in a manner to promote quality patient care and assure a positive patient experience.\n- Strong verbal and written communication skills and negotiation skills\n- Must have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.\n- Intermediate computer and technology skills.\n- Ability to promote teamwork and to effectively function in teams.\n- Ability to interact effectively with key internal and external constituents using collaboration, and customer service skills that promote excellence in the patient experience.