Case Manager Full Time Days

Utilization Management

• Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
• Assures the patient is in the appropriate status and level of care based on Medical Necessity process and submits case for Secondary Physician review per Tenet policy
• Ensures timely communication of clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services
•   Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
•   Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
•   Identifies and documents Avoidable Days using the data to address opportunities for improvement
•   Prevents denials and disputes by communicating with payers and documenting relevant information
•   Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements.
(30% daily, essential)

Transition Management

•   Completes comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan for patients
•   Integrates key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan
•   Identifies patients at risk for readmission and applies appropriate intervention including risk assessment and referral to Social Work services and/or Complex Case Review
•   May delegate the implementation of the transition plan to LVN/LPN or Assistant staff. And follows up to ensure the transition plan is completed timely and accurately
•   Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers
•   Provides information to patients to make informed choices when community services per Tenet policy
•   Completes Final Discharge Disposition Form Assessment for Medicare patients per Tenet policy
•   Identifies and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes documentation in the Tenet Case Management system to communicating information through clear, complete and concise documentation
(30% daily, essential)

Care Coordination

•   Screens patients for factors that may affect the progression of care and intervenes as needed to promote timely and appropriate throughput
•   Conducts assessments and stratifies patients at risk for readmission or in need of Case Management services
•   Ensures the plan of care is clinically appropriate, consistent with patient choice and available resources
•   Ensures consults, testing and procedures are sequenced to support the patients clinical needs with timely and efficient care delivery
•   Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
•   Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical outcomes
(15% daily, essential)

Education

•   Ensures and provides education to patients, physicians and the healthcare team relevant to the
o   Effective progression of care,
o   Appropriate level of care, and
o   Safe and timely patient transition
•   Provides patient and healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options
•   Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge
(15% daily, essential)

Compliance

•   Completes .edu’s and other required hospital education by the due date
•   Adheres to SRRMC Behavior Standards
•   Complies with San Ramon Regional Medical Center Policies/Procedures protecting patient information and the confidentiality of the information in accordance with the Federal and State regulations
•   Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
•   Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies
•   Operates within the LVN/LPN scope of practice as defined by state licensing regulations
•   Remains current with Tenet Case Management practices (10% daily, essential)

SUPERVISORY RESPONSIBILITIES:
May oversee work delegated to LVN/LPN Case Manager and/or Case Management Assistant/Discharge Planner

QUALIFICATIONS:

Minimum Education:
Required Graduate of Accredited School of Nursing BSN preferred

Minimum Experience:
Required at least two (2) years of recent Case Management acute hospital experience or Masters Degree in Case Management;
Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast paced environment, critical thinking and problem solving skills and computer literacy.

Licenses/Certificates/Credentials:
Current California Registered Nurses License
Accredited Care Manager (ACM) or Certified Case Manager (CCM) preferred

PHYSICAL DEMANDS:
Per Job Functional Match description

WORK ENVIRONMENT:
Individual works in a fast paced clinical and office environment.

TRAINING REQUIREMENTS
Must complete Tenet’s InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Completion of Compass Directional Training within 90 days of hire. Attendance at hospital and department orientation is required.
Department orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQual®, Transition Management, Utilization Management, and other topics specific to case management.

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Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.