Case Manager-Utilization Review

Loma Linda University Health; Loma Linda (CA); Hybrid; USD 92,000 - 125,000; Full time

Job summary

Loma Linda University Health in California is seeking a Case Manager for a full-time, day shift role with 8:00 am–4:30 pm hours and alternating weekends/holidays. The position offers a hybrid schedule with up to two remote days and three days in the office.

The Case Manager will join a Magnet Recognized academic medical center with STEMI receiving, comprehensive stroke and chest pain center designations, supporting patient-centered care and discharge planning.

Qualifications

• BSN required and two years hospital nursing experience.
• Two years of case management, utilization review, or discharge planning preferred in acute care.

Responsibilities

• Collaborate with care teams to develop and monitor interdisciplinary care plans.
• Ensure medical necessity and appropriate level of care from admission to discharge.
• Communicate effectively with patients, families, and staff and participate in governance activities.

Skills

Case management

Utilization review

Discharge planning

English proficiency

Education

BSN (Bachelor of Science in Nursing)

Tools

MS Office

Outlook

Electronic Medical Record (EMR)

Job description

This is a full time, day shift position, the schedule is 8am-4:30pm.

This role requires alternating weekends and holiday shifts.

The hyrbird schedule is for up to two days remote and three days in office.

Job Summary:

The Case Manager serves as a key member of the patient care delivery team in a Magnet Recognized large tertiary academic medical center with level one trauma designation, ST-Elevation Myocardial Infarction (STEMI) receiving center designation, and Comprehensive Stroke Center and Chest Pain Center accreditation. Works efficiently in a fast-paced environment and utilized clinical expertise, discretion and independent judgement in performing the nursing process (assessment, care planning, intervention, evaluation) within a patient-centered care professional practice model (Duffy's Quality-Caring Model) and as it relates to case management functions. Maintains a solid working knowledge of specialized case and utilization management methodologies and practices and applies concepts to everyday practice. Ensures medical appropriateness criteria (medical necessity) are met for level of care provided and is documented from admission through discharge. Practices in a collaborative health care environment to oversee implementation of a well-thought-out interdisciplinary plan of care with an individualized discharge plan that is comprehensive and best meets the continuing healthcare needs of the patient. Reevaluates plan of care and ensures continued appropriateness based on the patients changing needs and condition. Functions within the expectations of a professional nurse and meets nursing excellence standards to achieve and maintain Magnet Recognition as outlined by the American Nurses Credentialing Center. Represents nursing as an empowered profession and readily embraces new knowledge, innovations and improvements. Exhibits positivity and serves as an instrumental change agent and expertly minimizes resistance to change in the workforce, clinical practice and operational setting. Engages in opportunities to directly and/or indirectly influence decision-making for bedside clinical practice by participating in professional governance councils, committees, taskforces and staff meetings. Performs other duties as needed. and practices. Demonstrates ability to be an effective change-agent for implementation of new processes to achieve desired outcomes/performance measures. Performs other duties as needed.

Education and Experience:

Bachelor of Science degree in nursing (BSN) required. Minimum two years of hospital nursing experience required. Minimum two years of case management, utilization review, or discharge planning experience in acute care environment preferred.

Knowledge and Skills:

Basic knowledge of case and utilization management practice and methodologies and state and federal healthcare regulations and accreditation required. Able to: speak, read and write legibly in English (and Spanish preferred) with professional quality; use computer, printer and software programs necessary to the position, e.g., Microsoft Office Suite, Outlook, electronic medical record, electronic event reporting program. Relate and communicate positively, effectively and exhibit professional behavior at all times; work calmly and respond courteously when under pressure; be assertive and consistent in following policies; teach, and collaborate; accept direction; think critically; work independently with minimal supervision; perform basic math and statistical functions; manage multiple assignments effectively; organize and prioritize workload; problem solve; recall information with accuracy; pay close attention to detail; hear sufficiently for general conversation in person and on the telephone; identify and distinguish various sounds associated with the work place; see adequately to read computer screens, medical records, and written documents necessary to position.

Licensures and Certifications:

Active and unrestricted California Registered Nurse (RN) license required. Current Basic Life Support (BLS) certification issued by the American Heart Association required. Nationally recognized certification in Utilization Management or Case Management preferred.

Our mission is to continue the teaching and healing ministry of Jesus Christ. Our core values are compassion, excellence, humility, integrity, justice, teamwork and wholeness.