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Case Manager

Job Description

The Case Manager is responsible for planning, organizing, directing, coordinating and evaluating identified managed care patients following pre-established criteria to maintain high quality patient care.  The Case Manager assures that the department meets all regulatory requirements related to service area for DHS, The Joint Commission, and others as appropriate.  Working collaboratively with other managers to meet goals and solve problems is a requirement of this position.    


1.     Monitors patient care by reviewing Physician orders, test/lab results and nursing care.


 


2.     Monitors and facilitates Physician and nursing compliance with care management initiatives.


 


3.     Screens all admissions, verifies insurance coverage/authorization, appropriateness of admission and compliance with admission criteria.


 


4.     Reviews all patient charts for presence of legal documents if needed and patient's rights admission paperwork.


 


5.     Reviews all admissions for advance directive and refers those not screened to Social Services.


 


6.     Assists with integrating discharge plans into the multidisciplinary plan of care.


 


7.     Accurately gives patient information to third party payors; calls information to third party payors within 24 hours of review inquiry.


 


8.     Prevents Medicare and Medi-Cal denials by consistently applying SI/IS screens and educating physicians of the criteria.


 


9.     Monitors patient's condition and labs every two (2) days as needed.


 


10.  Identifies, documents and monitors intensity of service and severity of illness of targeted patients (Managed Care, Medicare and Medi-Cal) using InterQual Criteria.


 


11.  Participates in interdisciplinary care management rounds at least three times per week on assigned unit(s).


 


12.  Communicates verbally or in writing with physicians regarding documentation needs, discharge plans, over utilization of resources including length of stay.


 


13.  Assists Nursing Staff in making or facilitating appropriate referrals to Social Service, Hospice, etc.


 


14.  Communicates plan and coordination of the plan of care/discharge with patients' and patients' families.


 


15.  Collaboratively directs Nursing Staff in the development of realistic collaborative plans of care.


 


16.  Works with all health care team members to recognize and prevent over-utilization of resources.


 


17.  Monitors managed care patients utilizing outside facilities to ensure appropriate utilization (Managed Care Case Manager), facilitates timely transfer of out-of-network patients.


 


18.  Assists Manager of Case Management in educating/counseling Nursing Staff when identified as contributing to delays in service or avoidable patient days.


 


19.  Facilitates a smooth transition for patient transfer to other units, lower level of care or discharge.


 


Minimum Education:


Graduate from accredited school of Nursing


Bachelors in Science, Nursing (BSN) preferred


 


Minimum Experience/Skills:


Minimum of three (3) years' of Clinical experience in a healthcare setting


Previous Case Management experience preferred


 


Licensure:


Maintains current California Registered Nurse Licensure or has graduated from an accredited RN program and works directly under the supervision of a California licensed RN.


           


Certifications:


Maintains current BLS.


Prefer California Public Health Certification


 


Special:


Must have Knowledge of hospital protocol and procedures; familiarity with community resources and outside professional agencies; federal and state regulation governing hospital and home care.


Must have knowledge of and broad experience in acute nursing care.


Must be computer literate.


Must be able to multi-task.


 


EOE/Vet/Disability


           


 



Company Description
A little about us, with over 600 employees and in a growth mode, Oak Valley Hospital District is a full service, non-profit public hospital created to provide residents of Oakdale and the surrounding rural communities, with access to superior quality medical care. We also operate four community health centers providing primary care medical services and plan to expand this business as well. As an organization we take care of nearly 90,000 patients a year.



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