Registered Nurse (RN) / Case Manager

RiseMe; Fresno (CA); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Medical, dental, vision insurance

Life insurance

401k retirement plan

Paid time off

Opportunities for advancement

Job summary

Sante Health System in Fresno, CA is seeking an organized, personable Registered Nurse (RN) / Case Manager for a full-time role. You will coordinate medical management, reviews, and discharge planning to ensure quality patient care.

The position emphasizes utilization management, collaboration with insurers, and maintaining HIPAA-compliant data while supporting a multidisciplinary care team.

Qualifications

• Graduate of an accredited school of nursing.
• Minimum of one year of professional nursing experience in a clinic or hospital (5 years of case management experience preferred).
• Possess a State Registered RN license.
• CPR certification is preferred.

Responsibilities

• Conduct concurrent and ongoing reviews of patient documentation in the medical record.
• Perform utilization management based on applicable patient care protocols, length of stay and physician documentation using InterQual guidelines.
• Inpatient reviews telephonically from various hospital case managers as well as reviewing faxed cases. Daily reviewing of inpatient records via EPIC and EMR in the computer system.
• Assess physical and psychosocial patient and family needs necessary for case management.
• Work directly with insurance companies regarding verification of benefits and eligibility, for medical necessity.
• Manage cases involving severe illness or injuries requiring unique treatments and a high degree of medical expertise.
• Participate in multidisciplinary plan of care as necessary including identification of care outcomes and barriers.
• Assist in developing an appropriate hospital discharge plan and authorizing home health, skilled nursing facilities, sub-acute facilities, rehabilitation centers and durable medical equipment needs for the patient upon discharge.
• Follow discharged patients with case management consisting of but not limited to home phone calls, calls to patient's physician and others facilitating his outpatient care.
• Maintain current knowledge of Medicare, Medi-Cal and all health plans contracted with Santé.
• Provide assistance and education to staff and physicians in resolving questions or problems involving patient treatment plans, medical staff relations, interpersonal conflicts and patient care providers.

Skills

Nursing experience

Case management experience

InterQual knowledge

HIPAA awareness

Education

State Registered RN license

CPR certification (preferred)

Tools

EPIC EMR

AS400

MG 400 systems

Job description

Sante Health System is looking for organized, personable Registered Nurses (RNs) in the Fresno, CA area to apply to be a full-time Case Manager. This nursing/case management role is responsible for coordinating medical management functions. If you are ready to bring your skills to a healthcare organization that will value you, keep reading!

Our Registered Nurse (RN) / Case Manager enjoys competitive compensation, generous benefits, and a great work environment. If you are ready to build a satisfying career with an established and respected healthcare organization in the Central Valley.

QUALIFICATIONS

• Graduate of an accredited school of nursing
• Minimum of one year of professional nursing experience in a clinic or hospital (5 years of case management experience preferred)
• Possess a State Registered RN license
• CPR certification is preferred.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Conduct concurrent and ongoing reviews of patient documentation in the medical record.
2. Perform utilization management based on applicable patient care protocols, length of stay and physician documentation using InterQual guidelines.
3. Inpatient reviews telephonically from various hospital case managers as well as reviewing faxed cases. Daily reviewing of inpatient records via EPIC and EMR in the computer system.
4. Assess physical and psychosocial patient and family needs necessary for case management.
5. Work directly with insurance companies regarding verification of benefits and eligibility, for medical necessity.
6. Manage cases involving severe illness or injuries requiring unique treatments and a high degree of medical expertise.
7. Participate in multidisciplinary plan of care as necessary including identification of care outcomes and barriers.
8. Assist in developing an appropriate hospital discharge plan and authorizing home health, skilled nursing facilities, sub-acute facilities, rehabilitation centers and durable medical equipment needs for the patient upon discharge.
9. Follow discharged patients with case management consisting of but not limited to home phone calls, calls to patient's physician and others facilitating his outpatient care.
10. Maintain current knowledge of Medicare, Medi-Cal and all health plans contracted with Santé.
11. Provide assistance and education to staff and physicians in resolving questions or problems involving patient treatment plans, medical staff relations, interpersonal conflicts and patient care providers. Developing and maintaining effective working relationships with those contacted in the course of work.
12. Generate statistical reports and case summaries. Maintain patient demographics. Maintain a list of patient problems and diagnosis including problems not currently being managed for reference. Track patient's medications and lab results. Manage short-term and long-term goals and challenges. Track case interventions and case outcomes. Schedule calls and appointments. Maintain call notes and case notes. Maintain integrity of data security with HIPAA laws.
13. Input authorizations into the AS400 and the MG 400 systems on a daily basis.
14. Case review of prior authorization requests for Medical Director on a daily basis using medical justification and member's insurance coverage for authorizations.
15. Work closely with the senior products to deliver quality skilled nursing care at contracted facilities within the framework of financial efficiency. Monitoring patient's rehabilitation progresses enabling them to return to their prior living arrangements. Being in contact with the acute hospital's case managers to input authorizations for ambulance transfers from the acute to the skilled nursing facilities or to their homes for end of life care thru hospice.
16. Attend required meetings and participate in committees as requested.
17. Participate in professional development and maintain professional affiliations.
18. Maintain strictest patient confidentiality.
19. In the spirit of teamwork, employees are expected to follow any other job-related instructions and to perform any other job-related duties as requested.

PERFORMANCE REQUIREMENTS

Knowledge, Skills and Abilities:

• Knowledge of general clerical office procedures
• Skill in operating a computer and basic office equipment
• Ability to handle large volumes of work expediently and accurately
• Ability to organize and prioritize work
• Ability to sort and file materials correctly by alphabetic or numeric systems
• Ability to work effectively with others
• Ability to communicate clearly
• Knowledge of professional nursing theory and practice and evaluate patient care
• Knowledge of organizational policies, regulations and procedures to administer patient care
• Knowledge of medical equipmentand instruments to administer patient care
• Knowledge of common safety hazards and precautions to establish a safe work environment
• Skill in applying and modifying the principles, methods and techniques of professional nursing to provide on-going patient care
• Skill in identifying problems and recommending solutions
• Skill in preparing and maintaining records, writing reports, and responding to correspondence
• Skill in developing and maintaining department quality assurance
• Skill in establishing and maintaining effective working relationships with patients, medical staff and the public
• Ability to maintain quality control standards
• Ability to react calmly and effectively in emergency situations
• Ability to interpret, adapt and apply guidelines and procedures
• Ability to communicate clearly

A DAY IN THE LIFE OF A REGISTERED NURSE (RN) / CASE MANAGER

At our healthcare organization, you manage cases involving severe illness or injuries requiring unique treatments. With excellent organizational skills, you coordinate all services provided to our patients as well as the proper implementation of these services. This allows you to ensure the quality as well as the appropriateness of care. You assess physical and psychosocial patient and family needs necessary for case management. You provide assistance and education to staff and physicians in resolving questions or problems involving patient treatment plans, medical staff relations, interpersonal conflicts, and patient care providers. By participating in multidisciplinary plan of care meetings as necessary, you are able to regularly review and update our patients' care plans to fit their needs and identify outcomes and barriers.

You perform inpatient reviews over the phone daily. Working closely with the senior products to deliver quality skilled nursing care at contracted facilities, you monitor patients' rehabilitation progress enabling them to return to their prior living arrangements. You also assist in developing an appropriate hospital discharge plan and authorizing home health, skilled nursing facilities, sub-acute facilities, rehabilitation centers, and durable medical equipment needs for the patient upon discharge. Once patients are discharged, you continue your case management responsibilities by following up with home phone calls and calls to physicians who are facilitating outpatient care.

You perform utilization management based on applicable patient care protocols, length of stay, and physician documentation using InterQual guidelines. You work directly with insurance companies regarding verification of benefits and eligibility. With great attention to detail and always maintaining confidentiality, you generate statistical reports and case summaries. Your ability to expertly juggle case management, quality management, utilization management, disease management, and risk management is essential to your success as a Registered Nurse (RN) / Case Manager. It is rewarding to know you play a vital role in providing our patients with the best care possible.

ABOUT SANTE HEALTH SYSTEM

Sante Health System is a Management Services Organization that serves multiple clients. "Sante" is the French word for health. Our name symbolizes our commitment to good health, progressive care, and leadership in our community.

Sante is one of the largest healthcare claims and billing management companies in Central California. The strength of Sante is the extraordinary network of physicians, health plans, and other health service providers it offers the people of our valley. Sante coordinates with physicians, health plans, hospitals, and ancillary providers to ultimately benefit the patient in a managed care environment. Sante Health System provides numerous client services such as billing, claims processing, contracting, credentialing, finance, human resources, information services, marketing/communications, physician services, practice management, provider relations, quality improvement, and utilization management.

Sante is celebrating over 30 years in service to the community. We deeply understand that we would not be successful in enhancing the quality of life of our patients without our incredible team. This is why we have created a work culture that is comprised of talented, driven, dedicated, innovative, and service-driven professionals. We provide competitive pay, excellent benefits including medical, dental, vision, and life insurance, 401k retirement plan, paid time off, and opportunities for advancement. Being part of our team is like being part of a big family. Join our team and make Sante Health System your home away from home.

Do you have exceptional verbal and written communication skills? Are you compassionate and able to easily build relationships? Are you a team player? Do you have excellent organizational skills? If so, we want to meet you!

www.santehealth.net