Case Manager, Pre Admitting

careers-ahmchealth; Anaheim (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

AHMC- Anaheim Regional Medical Center seeks an RN Case Manager to evaluate admissions, concurrent stays, and discharge readiness using Milliman & Robertson and InterQual criteria.

You will ensure the correct level of care across critical, telemetry, acute, and observation for all patients.

Qualifications

• Education/Training/Experience: 2 years Utilization Management/Case Management preferred in acute care setting.
• Working knowledge of Interqual, Intensity of Service/Severity of Illness criteria.
• Working knowledge of Title XVII and Title XIX.
• Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, and Managed Care.
• Ability to negotiate orders with the physicians to assign alternate levels of care.
• Working knowledge of community resources.
• Discharge planning, Home Health, DME and SNF’s.
• Ability to manage high volume caseloads and improve patient/physician satisfaction.
• Excellent oral and written communication, interpersonal, problem-solving, conflict resolution, time management and negotiation skills.
• Strong clinical assessment and critical thinking for utilization review/discharge planning.

Responsibilities

• The RN Case Manager evaluates admissions, concurrent stay and readiness for discharge using Milliman & Robertson and InterQual criteria.
• Ensures correct level of care: critical, telemetry, acute, observation for all patients.
• Collaborates with Social Workers, Nursing, Financial Counselors and Medical Staff to coordinate care.
• The role supports AHMC- Anaheim Regional Medical Center mission and strategic plan.

Skills

Utilization Management

Case Management

InterQual criteria

Medicare/Medi-Cal knowledge

Reimbursement knowledge

Discharge planning

Collaboration

Negotiation with physicians

Communication skills

Clinical assessment

High volume caseload

Computer skills (Word/Excel/PowerPoint

Education

RN license in California

BSN preferred

Certified Case Manager preferred

Tools

InterQual criteria tools

Job description

Overview

The RN Case Manager uses Milliman & Robertson and InterQual criteria to evaluate the appropriateness of admissions, concurrent stay and readiness for discharge. She/he assures the correct level of care: critical, telemetry, acute, observation, for all patients. The Case Manager provides an efficient, coordinated approach to clinical management, with an emphasis on discharge planning, care coordination and utilization management activities for select patient populations across the continuum of programs and services at AHMC. The essential functions of the RN Case Manager require constant collaboration with the Social Workers, Nursing staff, Financial Counselors, Medical Staff to coordinate the care of patients in a proactive manner.

The position requires the full understanding and active participation in fulfilling the mission of AHMC- Anaheim Regional Medical Center. It is expected that the employee demonstrates behavior consistent with the core values. The employee shall support AHMC- Anaheim Regional Medical Center strategic plan and goals and direction of the performance improvement plan.

Responsibilities

The RN Case Manager uses Milliman & Robertson and InterQual criteria to evaluate the appropriateness of admissions, concurrent stay and readiness for discharge. She/he assures the correct level of care: critical, telemetry, acute, observation, for all patients. The Case Manager provides an efficient, coordinated approach to clinical management, with an emphasis on discharge planning, care coordination and utilization management activities for select patient populations across the continuum of programs and services at AHMC. The essential functions of the RN Case Manager require constant collaboration with the Social Workers, Nursing staff, Financial Counselors, Medical Staff to coordinate the care of patients in a proactive manner.

The position requires the full understanding and active participation in fulfilling the mission of AHMC- Anaheim Regional Medical Center. It is expected that the employee demonstrates behavior consistent with the core values. The employee shall support AHMC- Anaheim Regional Medical Center strategic plan and goals and direction of the performance improvement plan.

Qualifications

Education/Training/Experience

• 2 years Utilization Management/Case Management experience preferred in acute care setting.
• Working knowledge of Interqual, Intensity of Service/Severity of Illness criteria.
• Working knowledge of Title XVII and Title XIX.
• Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, and Managed Care is required.
• Ability to negotiate orders with the physicians in order to assign alternate levels of care.
• Working knowledge of community resources.
• Working knowledge of methods to resolve patient needs such as discharge planning, Home Health, DME and SNF’s.
• Ability to manage smoothly and increase patient/physician satisfaction while staying within guidelines.
• Ability to track outcomes and report findings.
• Able to problem solve effectively.
• Ability to use clinical knowledge to identify potential quality issues, delays in service, post-acute care needs required.
• Must have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, positive personal influence and negotiation skills.
• Must have strong clinical assessment and critical thinking skills necessary to provide utilization review/discharge planning services appropriate to patients with complex medical, emotional and social needs.
• Must have the ability to work in a high volume caseload environment and deal effectively with rapidly changing priorities.
• Excellent computer skills with word, excel and power point.

Licenses/Certifications

RN License in the State of California required. BSN preferred. Certified Case Manager preferred.