Patient Care Coordinator Case Manager


Santa Clara, CA

What you'll be doing

The patient care coordinator case manager performs daily preadmission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge. The candidate escalates utilization and system problems which have not been resolved at the local level to the next level (rm/um director, ccl, dho, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams. S/he educates other health care team members on utilization and cost containment initiatives. Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care). S/he ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning, and obtaining authorizations/approvals as needed for outside services for the patient. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other healthcare providers and agencies. Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols. Participates in the development and implementation of guidelines, preprinted physician orders, care paths, etc. For patient care. Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, drgs, los, etc. Participates in the development, implementation, communication, maintenance and monitoring of local um work plan initiatives. Shares accountability with the um manager for planning, developing, and managing the department budget. Performs other duties as assigned.

What your background should be

Minimum 2 years of experience in direct patient care delivery & management related job required. Current california rn license and bls certificate required. Minimum 2 years of experience in utilization review, case management, and discharge planning preferred. The candidate should have knowledge of the nurse practice act, tjc, dmhc, cms, ncqa, hippa, erisa, emtala & all other applicable federal/state/local laws & regulations. S/he should have demonstrated strong communication and customer service skills, problem-solving, critical thinking, & clinical judgment abilities. The incumbent should have fundamental word processing & computer navigation skills & the ability to interpret & use analytic data in day-to-day operations. Knowledge of healthcare benefits associated with various business lines (medicare/kpsa, commercial/kfh, medi-cal, federal, etc.). S/he must be able to work in a labor/management partnership environment.

Required Schooling / Training

BSN or bachelor degree in health care related field or diploma/associate degree in nursing from an accredited school of nursing. Master degree preferred.

Who is the client company

The client is an integrated managed care organization in the united states.
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