RN Case Manager: Care Coordination Pro

Sante Health System, Inc; Fresno (CA); On-site; USD 137,760,000 - 198,374,000; Full time

Benefits offered by this job

Competitive benefits

401k retirement plan

Paid time off

Medical, dental, vision insurance

Job summary

Sante Health System is seeking an organized, personable Registered Nurse (RN) in the Fresno, CA area to join as a full-time Case Manager. This role coordinates medical management functions and collaborates with insurance providers for authorization and benefits verification.

You will conduct concurrent reviews, assess patient and family needs, and develop discharge plans while maintaining HIPAA confidentiality and quality of care.

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.
• Generating statistical reports and case summaries. Maintain patient demographics. Maintain a list of patient problems and diagnosis including problems not currently being managed. Track 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 data security with HIPAA laws.
• Input authorizations into the AS400 and the MG 400 systems daily.
• Case review of prior authorization requests for Medical Director daily using medical justification and member\'s insurance coverage for authorizations.
• Work closely with the senior products to deliver quality skilled nursing care at contracted facilities within the framework of financial efficiency. Monitor patient rehabilitation progress enabling return to prior living arrangements. Input authorizations for ambulance transfers from acute to SNF or home for end of life care through hospice.
• Attend required meetings and participate in committees as requested.
• Participate in professional development and maintain professional affiliations.
• Maintain strictest patient confidentiality.
• Perform other job-related duties as requested.

Skills

Clinical nursing

Case management

InterQual guidelines

EPIC EMR

Patient assessment

Communication

HIPAA compliance

Education

Graduation from accredited nursing program

Registered Nurse license (State)

CPR certification preferred

Tools

EPIC EMR

AS400

MG400

Job description

Sante Health System is seeking an organized, personable Registered Nurse (RN) in the Fresno, CA area to join as a full-time Case Manager. This role coordinates medical management functions and collaborates with insurance providers for authorization and benefits verification.

You will conduct concurrent reviews, assess patient and family needs, and develop discharge plans while maintaining HIPAA confidentiality and quality of care.