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Inpatient and SNF Case Manager - RI CRC
We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.
The Inpatient/SNF Case Manager is responsible for coordination of daily Inpatient/SNF services including assessments, treatment planning, monitoring, evaluation, documentation and discharge planning function in accordance with CRC policies, procedure and processes. Interacts with the Medical Directors, facility staff and hospitalists on a daily basis to determine medical necessity of admission, continued stay or any discharge planning needs. On Call rotation for non-business hours, weekends and holidays.Job Responsibilities/Duties
- Level Effectively manages patients either telephonically or onsite during their hospitalization/SNF to ensure the appropriate level of care is provided for the patient's severity of illness. Utilizes the appropriate tests and diagnostics in the right facilities to facilitate the highest level of care in the most efficient manner. Communicates effectively with the facility staff and hospitalist to gather clinical information through verbal and written communications and provides timely and accurate responses to request information or provide authorization decisions. Updates clinical information in the electronic medical management record system with treatment plan, objectives, results and next steps. Documents all information accurately with approved criteria utilizing the goal length of stay. Initiates and continues direct communication with health care providers involved with the care of the member, including the IPA or Hospitalist Group if applicable, to obtain complete and accurate information. Applies appropriate benefits. Utilizes current approved criteria along with clinical experience to make authorization decisions. Identifies cases not meeting criteria and provides clinical information and rationale to the Medical Director for review and determination. Actively participates in daily rounds with current and accurate clinical information.
- Responsible for timely development of denial letter language and member/provider notification regarding Medical Director's review determination. Identifies and refers cases appropriately for CCS, High Risk, Hospice/Palliative, SNF, QI and Disease Management, per policy, and documents referral in case files. Refers cases to the Medical Direct as appropriate for denial.
- Anticipates and initiates discharge planning within twenty-four hours (24 hours) of admission, completes post discharge call within 24-48 hours of acute discharge or SNF, to identify barriers and prevent readmission. Identifies post discharge care needs and refer to the appropriate outpatient programs and/or providers. Interacts with hospitalists, facility staff and patients daily to evaluate plan of care including discharge planning to determine that patients are receiving quality care and appropriate discharge disposition. Applies medical knowledge to authorize outpatient services as an alternative to hospitalization when appropriate.
- Identifies and reports under and over utilization of medical services, delays in service by hospital or treatment and quality care issues to the Medical Director, and/or the QI department. Actively participates in internal quality and workflow enhancement projects, and other duties, as assigned. Identifies and reports departmental operational issues and resource needs to the appropriate management personnel.
Minimum Education: Active, unrestricted RN license from the State of Rhode Island.
Minimum Experience: Three to five (3-5) years experience in a Medical Group or Health Plan setting with strong clinical skills and critical thinking skills. Four (4) years experience in managed care setting. Experience with Microsoft Office Word. Recommend but not required, knowledge of NCQA, Medicare, Health Plan, DHS and State standards and other regulatory requirements. Make independent decisions. Knowledge of nationally recognized criteria InterQual, etc. Maintains strong working relations with internal and external customer. Effectively articulates clinical and non-clinical information to persons of all levels. Communicates positively and effectively. Maintains member confidence and protects operations by keeping claim information confidential in compliance with HIPPA requirements.
Req. Certification/Licensure: Active, unrestricted RN license from the State of Rhode Island.Employee Value Proposition
Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:
- Company 401K
- Medical, dental, vision insurance
- Paid time-off
- Life insurance
Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol. Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm. For this reason, we require applicants to pass a screening for drug use as a condition of employment. This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.How to Apply
To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!
We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.
EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm
Keywords: RN, Case Manager, Discharge Planning, Treatment Planning, Inpatient, Diagnostics, EMR, Medical Group, Managed Care, Hospitals, HIPPA, Medicare, Health Plans, DHS, NCQA, InterQual, Clinical, Patient Care.
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