Case Manager (TC) (CNA)

Job Description

Located in Templeton amongst the oak trees, Adventist Health Twin Cities has been serving northern San Luis Obispo County since 1977. Comprised of a 122-bed acute care facility, our team provides exceptional care in emergency medicine, orthopedics, obstetrics, digestive disorders, wound care, and various medical, surgical and outpatient services. Locals enjoy weekly farmers markets in downtown Templeton, farm-to-fork dining, beautiful landscapes for hiking and biking, and beach days just fifteen minutes away at Cambria and Morro Bay.

Job Summary

The RN Case Manager is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity and to assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including:

• Utilization Management supporting medical necessity and denial prevention
• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
• Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Education provided to physicians, patients, families and caregivers The individual’s responsibilities include the following activities: a) accurate medical necessity screening and submission for Physician Advisor review, b) care coordination, c) transition planning assessment and reassessment, d) implementation or oversight of implementation of the transition plan, e) leading and facilitating multi-disciplinary patient care conferences, f) managing concurrent disputes, g) making appropriate referrals to other departments, h ) identifying and referring complex patients to Social Work Services, i) communicating with patients and families about the plan of care, j) collaborating with physicians, office staff and ancillary departments, k) leading and facilitating Complex Case Review, l) assuring patient education is completed to support post-acute needs , m) timely complete and concise documentation in Case Management system, n ) maintenance of accurate patient demographic and insurance information, o) identification and documentation of potentially avoidable days, p) identification and reporting over and underutilization, q) and other duties as assigned. This position is represented by CNA.
  
  

Job Requirements

Education and Work Experience:

• Graduate of a school of nursing: Required
• Two years acute care RN experience: Required
• Experience in utilization review, discharge planning and/or home health: Preferred
• Recent experience in acute care hospital case management: Preferred
  
  

Licenses/Certifications

• Current RN license in state of practice: Required
• Accredited Case Manager (ACM): Preferred
• Registered Nurse (RN) license in state of practice: Required
  
  

Essential Functions

• Assists physicians in making admission decisions considering the use of observation, outpatient and inpatient status and payor guidelines.
• Demonstrates clear and effective communication with nursing and physicians. Works cooperatively with nursing, dietary, P.T. and social services to develop a safe discharge plan. Maintains patient, co-worker, and hospital privacy.
• Documentation is clear, concise, and legible. Develops a discharge plan that is safe and meets the patient’s needs. Need for follow-up case management is based on age, physical, psycho-social, financial or any other identified need which may affect progress towards return home or the next appropriate level of care. Obtains psycho/social assessment according to discharge planning protocol for all age groups. Reviews medical history, physical examination, and all available assessment data to assist in developing the discharge plan. Collects information needed to begin discharge planning in a timely manner, and initiates contact with patient and/or family. Reviews care and progress on assigned patients as often as necessary, but no less than every 72 hours and documents in the discharge planning notes. Coordinates team or family conferences as needed on complex patients. Ensures that the patient is medically stable for discharge from the inpatient setting and that the patient and family are prepared educationally, emotionally and functionally for discharge. Maintains a reference network of health systems and community resources in order to adequately plan for discharge. Uses Interqual and CMS programs for assessment and discharge planning.
• Assist in the development and education of new staff members. Attends and participates in staff meetings. Completes mandatory modules as required. Successfully adapts to changes in the unit, environment, and workflow.
• Obtains optimal coverage for patients by furnishing appropriate medical information to insurance carriers. Notifies review companies of planned treatment, length of stay, progress, etc. and obtains initial certification. Refers appropriate patients to the MEP (financial counselor). Presents letters of denial of coverage when appropriate.
• Performs other job-related duties as assigned.
  
  

Organizational Requirements

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.