Case Manager - Care Management

Company: St. Joseph Health
Location: Apple Valley
Posted on: May 3, 2021

Job Description:

We are looking for a Case Manager for the Care Management Department at St. Mary Medical Center.

Location: Apple Valley, CA

Work Schedule: Full Time - 80 Biweekly Hours

Shift: 8-hour, Days

Job Summary:

Manages specific patients throughout their admission to ensure the availability of sufficient clinical and medical center resources. Communicates on a daily basis with medical staff, medical center personnel and outside resources to ensure the appropriate utilization of resources according to clinical and financial standards. Monitors the medical record for variances to clinical and financial standards and intervenes to achieve the optimum outcome for the patient and the medical center. Is able to incorporate risk management and infection control knowledge for the purpose of assisting the healthcare team to achieve a desired outcome. Identifies issues, which expose the organization to liability and financial risk, and assists to minimize the risk by collaborating with management, medical staff and medical center personnel. Provides payor/utilization review organizations with concurrent retrospective utilization review required for reimbursement.

Essential Functions:

• Supports the values and mission of St. Mary Medical Center and practices the core values when interacting with those served by the Medical Center.

• Oversees the multidisciplinary assessment, development and implementation of a comprehensive plan of care, discharge goal, and evaluation of patients' clinical course through the continuum.

• Coordinates utilization activities of patient care using UR criteria (InterQual) - to ensure appropriate admission, length of stay, resource management, and maximum payer reimbursement.

• Identifies high-risk patients and refer to social services and / or community case management.

• Communicates appropriate information to third party payers.

• Coordinates activities related to discharge planning with patient, family, physician, and other health care team members.

• Coordinates transfers to other facilities including facility and transport authorizations if necessary (REFERENCE EMTALA).

• Facilitates the Clinical Documentation Program (CDI) for Medicare DRG assignment as assigned.

• Serves as a resource to physicians, admitting department, financial counselors, business office.

• Documents assessment and discharge plan in the medical record.

• Has knowledge of regulatory requirements in Continuum of Care and clinical areas of responsibility (TJC, TITLE 22, CONDITIONS OF PARTICIPATION).

• Assures appropriate documentation for receiving maximum reimbursement under regulatory guidelines and contractual agreements, specifically Medicare, Medi-Cal, HMO's and other payer sources.

• Processes payer denials and appeals as assigned.

• Implements denial process when necessary with appropriate denial letters as per CMRI and / or payer source requirements.

• Coordinates Inter-Disciplinary care conferences as indicated. Actively participates in extended length of stay meetings using InterQual criteria and addressing pain management, end of life, and ethics issues.

• Participates in hospital / health-system / community teams as indicated.

• Identifies referrals to infection control, risk and quality management.

• Participates in collecting, monitoring, reporting and analyzing of data as requested.

• Admission Care Manager:

• Works collaboratively with the ministry to provide clinical reviews of all ED/Direct admissions for recommendation of proper admission status.

• Able to use the patient's clinical presentation, initial diagnosis and physician's expected plan of care, in collaboration with Milliman Guidelines to determine whether the patient is appropriate for hospital admission and make a recommendation for the level of admission status.

• Must have excellent clinical and critical thinking skills; have effective verbal skills to collaborate with physicians, and demonstrate knowledge of the continuum of care to understand what care can be provided at different levels of care (i.e.: Inpatient, Observation, Outpatient).

• Capture and utilize data, trends and reports to proactively identify opportunities to improve processes and promote leading practice through the improving performance model.

Skills:

• Demonstrated knowledge of Microsoft PC applications, internet/web based applications.

• Admission Care Manager:

• Strong clinical, communication and multitasking skills.

• Pass Interrater Reliability Test with a score of 88% or above.

Minimum Position Qualifications:

Education:

• Associate's Degree in Nursing or Graduation/diploma from a school of nursing.

• Coursework/Training - Environmental Orientation due within 30 days of hire.

• Coursework/Training - Case Management Competency due within 90 days of hire.

• Coursework/Training - General Nurse Competency due within 30 days of hire.

Experience:

• 3 years Acute nursing experience or Case management experience.

• Admission Care Manager: 2 years Hospital clinical experience as well as Case Management/Utilization review experience.

Licenses and Certifications:

• Current California RN License by evidence of Primary Source Verification.

• BLS Certification.

Preferred Position Qualifications:

Experience:

• 3 years Acute nursing experience, with evidence of progressive clinical experience

• Admission Care Manager: ED/ICU/Cardia/Tele experience.

License/Certification: CCM

St. Mary Medical Center (SMMC) is an acute care hospital with 213 beds and over 1,750 employees making it one of the region's largest employers serving communities of the High Desert. The facility was constructed in 1956 and joined the St. Joseph Health System in 1992.

This facility has the only Neonatal Care Unit in the High Desert Accredited by California Children Services and has been granted approval as a Special Hospital with the California Children's Services Community Neonatal Intensive Care Unit. St. Mary was accredited as a primary Stroke Receiving Center in 2018, the only stroke-receiving center in the High Desert.

The Services and Clinical Specialties offered at this Hospital are Diabetes Education, Emergency Services, Heart and Vascular Services, Imaging Services, Rehabilitation Services, Respiratory Services, Robotic Surgery Services, Surgical Services, Women & Children's Services and Wound Care and Hyperbaric Medicine.

Keywords: St. Joseph Health, Apple Valley , Case Manager - Care Management, Other , Apple Valley, California