Case Management Utilization RN

Job Summary

Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and continued stays. Makes recommendations to physicians for alternate levels of care when a patient does not meet the medical necessity for inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver and patient advocate, managing patients in the most cost-effective way without compromising quality.

Transfers stable non-members to planned health care facilities and is responsible for complying with AB 1203 Post Stabilization notification. Must be able to work collaboratively with the multidisciplinary team, multitask, and work in a fast-paced environment.

Essential Responsibilities

• Plans, develops, assesses and evaluates care provided to members.
• Collaborates with physicians, other members of the multidisciplinary health care team, and patient/family in the development, implementation and documentation of individualized plans of care to ensure continuity, quality and appropriate resource use.
• Recommends alternative levels of care and ensures compliance with federal, state and local requirements.
• Assesses high-risk patients in need of post-hospital care planning, and develops and coordinates a discharge plan to meet patients' identified needs.
• Communicates the plan to physicians, patients, family/caregivers, staff and appropriate community agencies.
• Reviews, monitors, evaluates and coordinates the patient's hospital stay to ensure appropriate and essential services are delivered timely and efficiently.
• Participates in Bed Huddles and carries out recommendations congruent with patients' needs.
• Coordinates the interdisciplinary approach to continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining authorizations/approvals for outside services.
• Conducts daily clinical reviews for utilization/quality management activities across outpatient, emergency room, inpatient and non-KFH settings.
• Acts as a liaison between the inpatient facility and referral facilities/agencies, and provides case management to referred patients.
• Refers patients to community resources to meet post-hospital needs, and coordinates transfer of patients to appropriate facilities, maintaining required documentation.
• Adheres to internal and external regulatory and accreditation requirements, including TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL.
• Educates the healthcare team on roles and responsibilities in discharge planning, and provides patients with education to assist with discharge and cope with psychological aspects of illness.
• Reports unusual occurrences related to quality, risk and/or patient safety per established protocols.
• Reviews and analyzes utilization patterns, trends and problems, and participates in the collection and analysis of data for special studies and routine utilization monitoring.
• Coordinates and facilitates care planning rounds and patient/family conferences as needed.
• Participates in committees, teams or other work projects/duties as assigned.