RN Case Manager/Utilization Review (Float) - Case Management - Full Time 8 Hour Days (Non-Exemp[...]

RN Case Manager / Utilization Review (Float) - Case Management - Full Time 8 Hour Days (Non-Exempt) (Union)

Keck Medicine of USC

Be one of the first applicants, read the complete overview of the role below, then send your application for consideration.

Hospital

Los Angeles, California

The RN Float Case Manager and Utilization Review Nurse provides coverage for an RN Case Manager or RN Utilization Review Nurse.

The RN Float Case Manager and Utilization Review Nurse is assigned to function in the role of either a RN Case Manager or RN Utilization Review Nurse, as provided below.

When functioning in the role of a RN Case Manager :

In collaboration with the interdisciplinary team, provides care coordination services evaluating options and services required to meet an individual's health care needs to promote cost-effective, quality outcomes.

Serves as a consultant to members of the health care team in the management of specific patient populations. The RN case manager role integrates the functions of utilization management, quality management, discharge planning assessment, and coordination of post-hospital care services, including transfers to an alternative level of care.

When functioning in the role of a RN Utilization Review Nurse :

The RN Utilization Management Specialist coordinates communication with admitting financial counselors, case management team, providers, patient financial services, and payers to ensure all services provided by the hospital are authorized by appropriate payer.

The RN Utilization Management Specialist confers and reviews with physicians on medical admitting information to assess medical necessity and uses evidence-based criteria to consider the anticipated length of stay, level of care, intensity of service to support access to services.

The RN Utilization Management Specialist facilitates timely transmission of admission, concurrent and discharge reviews to the appropriate payer to ensure all days are authorized and documented.

Clinical reviews and continued stay authorizations will be documented in the appropriate electronic system.

Essential Duties :

• Able to effectively manage a minimum case load of 18-20 patients.
• Completes initial discharge planning evaluation within one business day.
• Actively participates in multidisciplinary rounds and discharge huddles as required.
• Identifies high risk indicators for discharge and / or needs for psychosocial interventions.
• Analyzes and interprets data in collaboration with patient, family, physician, health care team to develop a plan of care.
• Develops and implements referrals / placements / interventions.
• Notifies attending physician and medical physician advisor of any discharge planning barriers or issues.
• Demonstrates collaborative working relationship with social workers.
• Coordinates acute to acute transfers as requested by payers.
• Adheres to regulatory requirements as defined by CMS Conditions of Participation.
• Serves as a consultant to the health care team to identify financial issues that may affect care.
• Participates in the education of health care team members.
• Educates physicians and health care team on patient status, as appropriate.
• Delegates and supports team members to facilitate discharge planning.
• Participates in InterQual competency testing.
• Participates in hospital quality improvement processes.
• Identifies compliance and ethical issues and reports appropriately.
• Work with post acute services to address educational needs.
• Identifies and creates discharge planning solutions.
• Enters information concurrently into the electronic medical record.
• Participates in appeal process.
• Supports the needs of the department with other duties as assigned.

RN Utilization Review Nurse - Position Accountabilities :

• Validates patient registration status with physician order against medical necessity screening criteria.
• Applies evidence-based medical necessity screening criteria.
• Performs admission, continued stay and discharge reviews.
• Ensures that all bedded outpatient services are screened for appropriate level of care status.
• Provides clinical review to health plans as required.
• Documents communication with payers and outcomes of discussions in electronic systems.
• Assists with denial management.
• Participates in hospital quality improvement processes.
• Maintains awareness of payer / reimbursement practices and requirements.
• Identifies compliance and ethical issues and reports appropriately.
• Performs other duties as requested / assigned.

Required Qualifications :

• 3 years Clinical experience.
• Knowledge of case management principles and healthcare management.
• Problem solving skills and ability to multi-task.

Preferred Qualifications :

• Bachelor's degree Nursing.
• 1 year Case management or utilization review experience within the last three years preferred.

Required Licenses / Certifications :

• Registered Nurse - RN (CA DCA).
• Basic Life Support (BLS) Healthcare Provider from American Heart Association.
• Fire Life Safety Training (LA City).

The hourly rate range for this position is $47.31 - $88.00. Factors considered when extending an offer include the scope and responsibilities of the position, the candidate's work experience, education / training, key skills, and market considerations.

REQ20142135 Posted Date : 09 / 04 / 2024

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