Case Manager Utilization RN-Per Diem

Socket.dev; Riverside (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Socket.dev seeks an experienced registered nurse to collaborate with physicians and the multidisciplinary team to coordinate admissions, screen for appropriateness, and plan safe, cost-efficient discharge paths. You will advocate for patients, coordinate post-acute referrals, ensure compliance with TJC, Medicare and Medi-Cal, and monitor utilization to maintain high-quality outcomes across settings.

This role requires strong critical thinking, organization and the ability to multitask in a

Qualifications

• Two (2) years RN experience in acute care or case management.
• Must hold a California RN license and BLS certification.
• Familiarity with utilization review and discharge planning processes.

Responsibilities

• Coordinate and screen admissions and discharge plans with a multidisciplinary team.
• Recommend alternative levels of care when medical necessity for inpatient hospitalization is not met.
• Educate patients and families and coordinate post-hospital resources.
• Ensure compliance with TJC, Medicare, Medi-Cal, and other regulatory standards.
• Perform daily reviews for utilization/quality management in various care settings.

Skills

Clinical nursing expertise

Case management

Communication skills

Education

Accredited RN program

Bachelor's degree in nursing (preferred)

Tools

Computer literacy

Job description

Job Summary:

Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment.

Essential Responsibilities:

• Plans, develops, assesses and evaluates care provided to members.
• Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use.
• Recommends alternative levels of care and ensures compliance with federal, state and local requirements.
• Assesses high risk patients in need of post-hospital care planning.
• Develops and coordinates the implementation of a discharge plan to meet patients identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies.
• Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently.
• Participates in the Bed Huddles and carries out recommendations congruent with the patients needs.
• Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families.
• Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities.
• Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred.
• Refers patients to community resources to meet post hospital needs.
• Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation.
• Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL.
• Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources.
• Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
• Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities.
• Reviews, analyzes and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
• Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed.
• Participates in committees, teams or other work projects/duties as assigned.

Basic Qualifications:

Experience:

• Two (2) years combined RN experience in an acute care setting or case management required.

Education:

• Completion of an accredited RN training program that allows graduates to take RN license exam.

License, Certification, Registration:

• Registered Nurse License (California)
• Basic Life Support

Additional Requirements:

• Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of Utilization review/management, discharge planning or case management.
• Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc.).
• Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem-solving skills.
• Demonstrated ability in planning, organizing, conflict resolution and negotiating skills.
• Computer literacy skills required.

Preferred Qualifications:

• Bachelors degree in nursing or healthcare related field.

Notes:

• Variable days