Job Description
POSITION SUMMARY
All employees are expected to perform their duties in alignment with the vision and values of the organization. The Case Manager is responsible for a variety of tasks that lead to a high level of customer satisfaction in the most cost-effective manner. Responsible for case management activities (includes utilization management and discharge planning activities) on designated units within the Hospital.
MAJOR RESPONSIBILITIES
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Independently performs initial assessment and daily concurrent chart reviews on all assigned patients utilizing approved hospital criteria (Medi-Cal and managed care patients require daily review regardless of criteria recommendation).
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Performs InterQual UR criteria screens for all patients and formulates discharge plans within 24 hours of admission.
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Proactively call/fax daily concurrent chart reviews to managed care companies (MCO)/medical groups according to payer contract/hospital policy. Document the review was called/faxed to MCO/medical group and document the dates approved for continued stay on the review record. Ensure MCO/medical group review call-in and approval dates are entered in the Paragon System to avoid payer denials.
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Respond to MCO or medical groups within 24 hours of receiving notice when concurrent or retrospective patient care reviews are requested.
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Independently performs timely retrospective chart reviews on all assigned patients utilizing approved hospital criteria: a) Perform managed care reviews within 24 hours of notice; b) Start Treatment Authorization Request (TAR) reviews with 24 hours of patient admission; and c) Initiate Medicare reviews within 24 hours of patient admission.
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Document concurrent TAR reviews daily. Complete retrospective TARs within five (5) business days of patient discharge.
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Discusses medical necessity/medical management issues with attending/responsible physicians and physician advisor, when indicated.
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If indicated, adhere to California Children Services (CCS) care management guidelines when responsible for managing CCS patients. Call/fax timely reviews according to CCS guidelines.
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Document the medical necessity InterQual criteria page number and next review date on UR reports/records.
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Refers cases not meeting criteria (including situations involving the timely provision of services) to Physician Advisor or Medical Director as appropriate.
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Obtains authorizations as required by third party payers for patients whose insurer has such requirements.
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Facilitates transfer of patients to other acute care facilities as required either due to third party payer requirements or county mandated indigent program.
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Maintains accurate records of all activities relating to the case management/utilization management process.
07/2016
Case Manager
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Maintains working knowledge of state and federal regulations and provider contracts governing coverage of inpatient services, i.e., Medicare, Medi-Cal, California Children Services, Genetically and Handicapped People Program.
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Interviews patients and families to obtain relevant information and develops discharge plan with input from other members of the health care team.
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Provides information and makes referrals as appropriate to implement the plan such as community resources, home health care, institutional placements, financial assistance, equipment needs, and catastrophic case management by third party payers.
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Refers patient n a vegetative state to regional center for placement as needed.
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Identifies situations needing psychosocial intervention and promptly refers them to Social
Services.
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Maintains accurate and through documentation of discharge planning activities to include those
mandated by third party payers. Records case management/utilization review-
management/discharge planning information in the medical record in a timely manner.
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Works collaboratively with the nursing staff/other disciplines to support and achieve the goals of
the collaborative care process.
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Handles all information obtained through the above process with utmost confidentiality.
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Works closely with other members of the health care team to facilitate the above process.
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Maintains objectivity and good interpersonal skills, which allow for effective interaction with a
wide variety of people.
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Participates in staff meetings, committee meetings, team conference and other activities as
assigned.
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Maintains accurate and updated review notes/records of UR activities as required.
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Identifies and refers situations requiring immediate intervention to Risk Management/QI
Director as indicated.
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Participates in the orientation of new employees or cross training of other case managers as
needed.
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Participates in mandatory UR/CM/DP staff education or hospital in-services.
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Participates in department quality improvement programs/projects/audits.
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Demonstrates an understanding of Mission Community Hospital’s vision, Mission and Guiding
Principles, and incorporates them into daily performance.
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Proactively seeks team-building and positive working relationships with all hospital staff and
physicians.
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Demonstrates and delivers excellent customer service (customer-centric) to both internal and
external customers.
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Promotes the business focus and vision of Mission Community Hospital.
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Demonstrates a continuing effort to improve the quality of his/her performance to better the
Organization.
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Performs other related duties as assigned.
The above statements reflect the essential functions considered necessary to describe the principle content of the job. They are not intended to be a complete statement of all work requirements or duties that may be inherent in the job.
QUALIFICATIONS:
Minimum of two (2) years direct patient care experience in an acute setting preferred. Previous experience in Case Management, Utilization Management or Discharge Planning preferred. Must be able to assess discharge-planning needs of a diverse cultural and ethnic population.
07/2016 2
Case Manager
Must be able to demonstrate the knowledge and skills necessary to provide appropriate case management specific to the age of the patients served on assigned units. Case Managers are assigned patients ranging in age from adult to geriatrics. Assignments are dependent upon the specific talent, experience and training of the Case Manager and the needs of the patient.
Must be able to exercise independent discretion and judgment (utilizing approved criteria) in the performance of the case management functions.
Minimum Education: Specialized Training:
Licensure:
Software:
Licensed Vocational Nurse Degree or Associate Degree in Nursing. Bachelor’s Degree in Nursing preferred.
Case Management, Utilization Management or Discharge Planning preferred. CCM or ACM certified preferred.
Licensed Vocational Nurse or Registered Nurse with current and valid California License.
Basic Microsoft computer skills preferred.
Job Tags
Full time, Contract work, Immediate start,