Job Summary

The RN Case Manager is responsible for coordination of care, utilization review, acting as a resource to patient, family and nursing units; referrals to clinical social worker for psycho-social issues and complicated discharge planning issues; and overseeing coordination of post-hospital care needs; interacting with insurance companies, medical groups, and community resources to ensure timely, efficient use of all services. Applies knowledge of the expected clinical process, available resources, medical necessity criteria, regulatory requirements, and relevant standards of care in anticipating patient needs. Responsible for case management across the continuum of care utilizing an interdisciplinary approach to managing patient throughput in a fiscally responsible manner to achieve optimal outcomes. Works as a member of a multidisciplinary team to actively facilitate those functions associated with the patient throughout an acute episode of care.

Licensure and Certification:

• Current CA RN license
• Current BLS provider card
• Case Management certification preferred

Education:

• Diploma, AA, BS in Nursing
• MS in Nursing preferred

Experience:

• Two (2) years as a Case Manager in an acute care setting or five years recent acute care nursing experience preferred.
• Demonstrates strong interpersonal skills, leadership ability, negotiation skills, and knowledge of hospital operations. General knowledge of the payer industry, resource management, reimbursement, and evidence-based clinical practice is essential.
• Knowledge of InterQual and/or Milliman preferred

Knowledge and Skills:

• Develops, maintains, and models professional, objective and value-oriented interpersonal skills. Continuously promotes a patient-centered philosophy.
• Maintains positive and proactive communication with patients, families, staff members, and physicians.
• Fosters team-building relationships
• Excellent organizational skills and the ability to problem solve are essential
• Strong interpersonal skills, leadership, negotiation skills, good leadership talent
• Knowledge of the payer industry, resource management, reimbursement, and evidence-based clinical practice is essential
• Ability to work independently