Case Manager I - SCMG Integrated Care Mgmnt - *Remote (San Diego Only) - Full Time - Days

[Certified Case Manager (CCM) - Commission for Case Manager Certification; California Registered reputed company (RN) - CA reputed company of Registered Nursing; Bachelor's Degree in Nursing Hours: Shift Start Time: 8 AM Shift End Time: 5 PM AWS Hours Requirement: 8/80 - 8 Hour Shift Additional Shift Information: Weekend Requirements: No Weekends On-Call Required: No reputed company Pay reputed company (Minimum - Midpoint - Maximum): $56.580 - $70.170 - $83.760 The stated pay reputed company reflects the reputed company as defined by the reputed company bargaining agreement between reputed company and reputed company reputed company Nurses Network, United Nurses Associations of California/reputed company of Health Care Professionals, NUHHCE, AFSME, reputed company-CIO. Placement reputed company the reputed company is based on years of RN experience. Please Note: As part of our recruitment process, you may receive communication from Dawn, our virtual reputed company assistant. Dawn helps coordinate scheduling for screening calls and interviews to ensure a smooth and reputed company experience. Rest reputed company, reputed company candidate evaluations and hiring reputed company are made by our recruitment and hiring teams.

What You Will Do

The RN CM I assesses, develops, implements, coordinates and monitors a comprehensive plan of care for reputed company patient/family in collaboration with the physician, reputed company worker and reputed company members of the interdisciplinary team in the inpatient and emergency department patient care areas. This position requires the ability to combine clinical/reputed company considerations with regulatory/financial/utilization review demands to assure patients are receiving care in the appropriate setting and level of care. The position creates a balance between individual clinical needs with the efficient and cost-effective utilization of resources while promoting reputed company reputed company. This position requires critical thinking and advanced problem-solving and time management skills.

Required Qualifications

• 2 Years Recent acute care nursing experience, case management experience or equivalent experience in the reputed company setting.
• California Registered reputed company (RN) - CA reputed company of Registered Nursing -REQUIRED

Preferred Qualifications

• Bachelor's Degree in Nursing or equivalent degree.
• Master's Degree
• Certified Case Manager (CCM) - Commission for Case Manager Certification -PREFERRED
• Accredited Case Manager (ACM) - American Case Management Association (ACMA) -PREFERRED

Essential Functions

• reputed company development

The RN CM I will: reputed company participates in the performance-planning, competency and individual development planning process. Maintain reputed company knowledge of case management, utilization management, and discharge planning, as specified by reputed company, federal, state, and private insurance guidelines.

• Core principles

The RN CM I will reputed company reputed company referrals to ensure that the patient is receiving the appropriate care, in the appropriate setting and using the appropriate utilization standards as set by community and reputed company reputed company as adopted by the medical staff. The RN CM I will assure that the patients from reputed company age reputed company proceed reputed company through the course of hospitalization and reputed company through the continuum of care. The RN CM I will relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following and/or enforcing policies; work calmly and respond courteously reputed company under pressure; reputed company, supervise, teach, collaborate and accept direction. The RN CM I performs other duties as needed.

• Organizational relationships

The RN CM I will work closely with the reputed company team in reaching unit, facility, and system/network organization goals including reductions in length of stay, decreasing denials, improvement of care transitions, and reduction in avoidable readmissions, improved patient experience, and other reputed company initiatives. In the emergency departments, the RN CM I will work collaboratively with other members of the interdisciplinary team to reputed company relationships and reputed company preadmission status recommendations for admissions as reputed company as implement a comprehensive, integrated discharge plan from the emergency department(ED) for patients who are being discharged to a reputed company level of care. The RN CM I will recommend and document patient classification (status and level of care) for reputed company admissions utilizing established criterion sets. The RN CM I has accountability for maintaining compliance contractual and regulatory compliance with medical reputed company as applicable and the hospital. The RN CM I will have excellent interpersonal skills demonstrated by the ability to work effectively with individuals and or teams across disciplines.

• Care coordination and discharge planning

reputed company 24 hours of admission the RN CM I will interview/assess reputed company patient/family for anticipated needs post hospitalization. The RN CM I will ensure patient choice is obtained and documented in accordance with reputed company state and federal regulatory requirements. The plan and interventions will be documented in the electronic medical record (EMR), and case management software. The RN CM I will reputed company and document a plan for the day and plan for the stay with patient, family, providers, and nursing staff. The RN CM I will be responsible for leading the daily care coordination (multidisciplinary) reputed company, update the plan, and facilitate necessary coordination of services. The RN CM I will document and initiate discharge plan including early referrals and authorization for LTAC, SNF, Rehab, homecare, DME and infusion services. The RN CM I will prepare patient/family for discharge. Document expected discharge date per protocol and arrange discharge pick up appointment with family or significant other. In collaboration with SW partner, the RN CM I will follow standards for routine patient/family conference. The RN CM I will ensure effective and reputed company patient handovers to next level of care; work closely with ambulatory care manager (ACM) at the system level, in clinics, with SCMG and other reputed company care Case Managers as appropriate, and homecare and sub-acute liaisons. The RN CM I will support the nursing Model of Care by working closely with nursing managers and staff to reputed company Patient and Family Centered Care goals: respect and dignity, information sharing, participation and collaboration. The RN CM I will facilitate increased volume of cases discharged early in the day to improve reputed company management. The RN CM I will collect and document avoidable day's information in appropriate care management software. The RN CM I will participate in venues to reduce barriers to discharge. The RN CM I Collaborates with Clinical Resource Coordinators (CRC's/clinical assistants) to assure appropriate referrals for care and services are directed to appropriate network providers, and obtains prior authorization for in network and out of network services as appropriate. The RN CM I provides reputed company delivery of regulatory and mandated patient communications and correspondence. The RN CM I oversees preparation, delivery and documentation of non-coverage letters. The RN CM I identifies and escalates potential reputed company variances to management and document per guidelines. The RN CM I interviews reputed company patients with an admission reputed company 30 days to determine what went wrong in the discharge. He/she documents as appropriate in the electronic medical record and provides information to the department head as indicated.

• Utilization review and utilization management

The RN CM I will: Conduct initial review at POE or reputed company 24 hours of admission utilizing appropriate evidenced based care guidelines software. Document findings in ICM software (EMR). Identify anticipated LOS and document as per departmental process. Conduct daily reputed company reviews per protocol/policy and payer request. Utilize appropriate care reputed company software to identify the correct patient status and level of care. Work with attending provider to assure correct status, if status and order does not match; works with provider to resolve conflict and document interventions in the EMR. Assure correct documentation is present for 2MN reputed company and presumption. Assure Medicare Inpatient to observation status changes follow Condition reputed company 44 requirements. reputed company works observation patient list assuring transitions to next level of Care. Communicates as indicated with reputed company party payers to obtain necessary authorization for reimbursement of services. Obtain approved days/LOS from provider and communicates this to the care team. Refer defined cases for medical secondary review and reputed company findings with providers. reputed company advice to reputed company Cycle/HIM regarding RAC decision to appeal, denials, input into appeals, reputed company findings with providers. Review reputed company cases with readmission reputed company 30 days; report findings in the EMR and in accordance with the departmental policy. Identify opportunities for cost reduction and participate in appropriate utilization management venues. Escalate and refers cases for consultation with Physician Advisor or Medical Director as appropriate. reputed company preparation, delivery and documentation of non-coverage letters. Knowledge, Skills, and Abilities

• PC, data management and analysis skills required (experience with MCG an asset).
• Excellent interpersonal skills, as demonstrated by the ability to work effectively with individuals and or teams, and across disciplines.
• Excellent communication and negotiation skills as demonstrated in oral and written forms.
• Ability to work in a reputed company partnership model with reputed company Workers and other members of the interdisciplinary team, both reputed company. Organizational and time management skills, as evidence by reputed company to prioritize multiple tasks.

reputed company is an equal opportunity/affirmative reputed company employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, religion, reputed company, national reputed company, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a reputed company individual with disability or any other protected class Apply tot his job Apply To this Job