Utilization Management Nurse Case Manager (Registered Nurse)

We value our employees! We offer long term employment opportunities with job stability, including supporting and encouraging career growth advancement. We offer Health, Dental and Vision insurance, Paid Time Off, 9 Paid Holidays, 403(b) with Matching Retirement Plan, Life insurance (paid by the company) and a team spirit workplace culture!

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

ADMINISTRATIVE FUNCTIONS

PURPOSE OF YOUR JOB DESCRIPTION

Under the supervision of the Center Manager, the Utilization Case Manager will work in close coordination with the primary providers to manage ongoing care and complex clinical situations. This position will facilitate the transfer of information between acute and post-acute providers, and assess any readmissions for cause. As well, as create proactive plans to avoid readmission. Additionally, the Utilization Case Manager is responsible for the supervision of the Level of Care RN, and the Home Care department, which currently consists of one RN and one LVN.

DELEGATION OF AUTHORITY

As the Utilization Management Nurse Case Manager, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

JOB FUNCTIONS

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

• Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.

• Collaborate with hospital and facility case management and hospitalist to improve processes.

• Performs prospective, initial, and retrospective reviews on all inpatient, facility, outpatient, and home health services assessing for appropriateness and medical necessity of the treatment requests using nationally recognized guidelines (InterQual or other criteria adopted by BCSC).

• Assess quality and clinical risk issues on a concurrent basis; reporting any recognized issues to the interdisciplinary team, providers and Medical Director and Director of quality and compliance.

• In conjunction with the Medical Director, evaluates and provides feedback as needed to treating physicians regarding participants discharge and home care plans and available covered services including identifying alternative levels of care that may be covered.

• Presents facility-patient status updates and addresses barriers to discharge/transition at interdisciplinary team meetings.

• Develops strong working relationships with outside contracted providers, case managers, and admissions department/personnel

• Assess documentation of medical records for completeness and relationship to the treatment plan and identifying gaps or barriers in treatment plans.

• Coordinates an interdisciplinary approach to support continuity of care. Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed by members.

• Facilitates on-going communication between staff and contracted providers to ensure authorizations are secured in a timely and efficient process.

• Coordinates care and services as needed (hospitalization, skilled care, home health, DME, etc) including home care department as needed.

• Coordinates identification and reporting of potential high dollar utilization cases.

• Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities and service providers

• Prepares and presents data analysis at Utilization Management meetings.

• Meets regularly with and collaborates with the physician advisor for Utilization Management.

• Investigates and follows up on complaints, grievances and quality issues related to patient acute or skilled level stays.

• Creates policies and procedures as needed in support of the UM Care Coordination.

• Works independently and as an effective member of the team.

• Multi-tasking in regards to projects and their respective activities, timelines and issues.

• Demonstrate ability to inter-relate with physicians, nurses, patients, internal departments, outside agencies, and the public.

• Demonstrated strong communication and customer service skills, problem solving, critical thinking, time management, organizational skills and clinical judgment abilities.

• Attends meetings and trainings as required.

• Adheres to and models JHA’s core values.

• Adheres to JHA and BCSC attendance and punctuality policies and practices.

• Consults with and educates the participant, family members and/or caregiver regarding the disease process, self-care techniques, prevention strategies and medical interventions.

• Provides the Primary Care Physician with a summary of health findings and any changes in a participant’s health condition pertaining to the role of utilization case manager

• Supports the Infection Control function in coordination with the Director of Quality and Compliance.

• Recognizes inappropriate participant care management or service delivery by other Interdisciplinary Team members and addresses directly and/or refers to the RN Clinic supervisor immediately.

• Identifies emergencies and takes appropriate action, including coordinating direct hospital admissions from clinic to hospital as necessary.

• Understands and demonstrates respect for participant rights and refers ethical issues to the BCSC Ethics Committee.

• Coordinates with the Pharmacist to support participant care.

• Coordinates with the Home Care Coordinator to support participant care at home.

• Complies with safety policies and procedures, identifying and immediately reporting any potential or actual unsafe acts or conditions to the Center Manager. Takes necessary measures to ensure a safe environment for oneself, co-workers, contractors, participants, visitors and others.

• Consistently meets or exceeds BCSC targets for productivity.

• Continually seeks better ways for delivering services and communicating with participants.

• Consistently meets or exceeds BCSC customer service targets.

• Effectively collaborates with staff peers and contractors to meet BCSC goals and further success.

• Complies with all policy and procedures of BCSC.

• Demonstrates proficiency in delivering age-specific care.

• Consistently meets or exceeds BCSC quality assessment and performance improvement targets.

• Performs other duties as assigned.

EDUCATION AND EXPERIENCE

• Degree and diplomas: Graduate of a school of professional nursing, BSN preferred.

• Certificates, Licenses: RN currently licensed by the California Board of Registered Nursing. Verification of completion of CPR (BLS) and first aid training. TB screening and successful completion of a health examination by a health care provider is required for employment. Must have valid California driver’s license.

• Experience: Three years nursing employment with at least one year caring for the frail or elderly. A Public Health Nursing background and/or experience with PACE (Program of All-inclusive Care for the Elderly) is preferred.

2 years of experience working in a managed care health plan, or 2 years of experience in utilization review, case management, and discharge planning or 2 years of experience in transitional care and acute care settings (critical care, acute hospital care, long term acute care, skilled nursing care, long term care).

• Knowledge of and/or experience with Managed Care Health plans, Medi-Cal/Medicaid, and/or Medicare

• Bilingual preferred.

Skills/Aptitudes: Nursing knowledge and skills necessary to treat participants and manage complex clinical situations. Ability to provide care for the frail elderly. Ability to work independently and within an Interdisciplinary Team. Good organizational and supervisory skills. Ability to handle complex interpersonal and clinical situations.