The purpose of the Case Manager I position supports the physician and interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates and coordinates the functions of utilization management, care progression and care transition.
The Case Manager I is accountable for a designated patient caseload and plans effectively to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include:
Facilitation of precertification and payor authorization processes
Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement
Application of process improvement methodologies in evaluating outcomes of care Coordinating communication with physicians.
The role reflects appropriate knowledge of RN scope of practice, current state requirements, CMS Conditions of Participation, EMTALA, The Patient Bill of Rights, AB1203 and other Federal or State regulatory agency requirements specific to Utilization Review and Discharge Planning.
The Care Manager partners with the medical staff, utilizes scientific evidence for best practices, and relevant data to manage the care of the patient over the continuum of their hospitalization. These activities include admission, continued, extended and discharge reviews in all reimbursement categories to determine medical necessity, assure high quality of care and efficient utilization of available healthcare resources, facilities and services. This position requires the full understanding and active participation in fulfilling the Mission of Martin Luther King, Jr. Community Hospital. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support Martin Luther King, Jr. Community Hospital's strategic plan and the goals and direction of the quality and performance improvement process activities.
Education Bachelor of Science degree in nursing (individuals without a BSN will be required to complete the degree within 5 years of their hire date).
Qualifications/Experience Minimum of one (1) to three (3) years of hospital inpatient or related experience required. Able to navigate and connect successfully with outside provider networks (Health Plans, IPA’s, and FQHC’s). Current California Nursing license Certification in Case Management preferred.
Special Skills/Knowledge Bilingual language skills preferred (Spanish) Basic computer skills Current Basic Life Support (BLS)