Nurse, Care Management

Alameda Health System; Oakland (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Alameda Health System seeks an experienced case management professional to coordinate continuum of care and discharge planning for a defined patient caseload. You will monitor clinical activities, assess care plans, and recommend appropriate levels of care within guidelines.

The role emphasizes collaboration with physicians, nursing, social work, and care management teams to ensure timely discharge and efficient resource utilization.

Qualifications

• Requires active RN license in California.
• BLS certification required; CPI training may be required depending on unit.
• Certification in Case Management (CCMC/ACM) preferred.
• Bilingual skills preferred.

Responsibilities

• Coordinate all utilization review functions including Medicare/Medi-Cal requirements and medical necessity criteria.
• Ensure appropriate level of care and accurate admission status; reference Interqual guidelines as needed.
• Document treatment plans, progress notes and discharge summaries per regulatory standards.
• Develop and coordinate comprehensive discharge plans with patients, families, and care team within 24 hours of admission.
• Collaborate with social work, nursing, and physicians to link patients to post-discharge services.
• Monitor performance targets for department improvements such as readmissions, throughput, and length of stay.

Skills

Care coordination

Care management

Utilization review

Discharge planning

Interdisciplinary teamwork

Education

Associate Degree in Nursing

Bachelor's of Nursing

Master's in Nursing

Job description

Summary

Responsible for coordinating continuum of care and discharge planning activities for a caseload of assigned patients; develops plans of care and discharge plans, monitors all clinical activities, makes recommendations for alternative levels of care, and identifies cost-effective protocols. Care Management provides Care Coordination, Compliance, Transition Coordination, and Utilization Management.

Duties & Essential Job Functions

NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

• Coordinates all utilization review functions, including response to payor requests for concurrent and retrospective review information including Medicare and MediCal regulations/requirements, avoidable days and quality issues. Applies Medical necessity criteria to determine level of care.
• Assures clinical interventions are appropriate for the admitting diagnosis and Level of Care that reflects the standard of care, as defined by the medical staff and the organization; identify inappropriate admit status based on identified criteria and ensures the patient is registered at the appropriate level of care. Utilizes McKesson Interqual® clinical guidelines; refers questionable cases to the CM Manager or physician advisor for determination.
• Takes appropriate action when cases do not meet criteria. Escalates to the attending physician, and the Care Management physician advisor of any concurrent denials.Prepares case reports;documents treatment plan, progress notes and discharge summary related information as required by Medicare, MediCal, Title 22 and other mandated regulations according to Department standards.Reassesses the patient’s condition when changes occur and revises the care plan when appropriate.
• Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social work, and other healthcare providers and agencies. Completes an initial assessment within 24 hours of admission and documents findings in the electronic health record. Processes referrals and authorizations that adhere to federal, state and local insurance regulatory agencies and offer patient choice per regulation.
• Identifies potential problems prevents and or resolves barriers to the discharge plan. Along with the social work team member
• Mobilize resources to effect rapid and timely movement of the patient through system to achieve targeted discharge times established by AHS.
• Identifies and mobilizes patients and family strengths to optimize use of healthcare and community resources. In coordination with patient and family wishes, guide/assist in securing needed post discharge services
• Collaborates with Care Management teams (i.e. Care Transition team and CM teams at other facilities) for high risk patients for timely follow-up appointments and confirms prior to discharge that complex patients are appropriately linked to community services.
• Provides community resource education and coaching, focusing on individual patient self-management principles. Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient.
• Communicates with physicians and multidisciplinary health team members to provide continuity of care, supporting and maintaining the multidisciplinary team approach to ensure effective resource utilization and appropriate level of care.
• Makes independent assessments and recommendations regarding course of action in complex situations.
• Confirm all applicable department and regulatory targets for department performance process improvements are attained (e.g., re admissions, throughput, LOS).

Minimum Qualifications

Required Education: Associate Degree in Nursing

Preferred Education: Bachelor's of Nursing

Preferred Education: Master's in Nursing

Required Experience: Three years of acute care nursing

Preferred Experience : Medical/surgical or critical care experience; broad clinical background. Within the last 3 years, experience in Case Management in an acute setting or utilization review at a medical group or health plan.

Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California, Active BLS - Basic Life Support Certification issued by the American Heart Association; other advanced life support certificates may be required per unit/department specialty according to patient care policies; CPI -Crisis Prevention Intervention Training (required for all positions at John George Psychiatric Pavilion; and certain positions in the Emergency Department).

Preferred Licenses/Certifications: Certification in Case Management, CCMC or ACM. Bilingual Preferred.