RN Case Manager Utilization


San Diego, CA

What you'll be doing

The RN case manager utilization is responsible to plans, develops, assesses, and evaluates care provided to members. The candidate collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality, and appropriate resource use. S/he recommends alternative levels of care and ensures compliance with federal, state and local requirements. Develops and coordinates the implementation of a discharge plan to meet patients identified needs. Communicates the plan to physicians, patient, family/caregivers, staff, and appropriate community agencies. Reviews, monitors, evaluates, and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the bed huddles and carries out recommendations congruent with the patients needs. The incumbent coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities. Maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. This position performs other tasks as assigned.

What your background should be

The candidate with 2 years of clinical experience as an RN in an acute care setting required. Current California RN and BLS license required. S/he should have demonstrated ability to utilize/apply the general and specialized principles, practices, techniques, and methods of utilization review/management, discharge planning, or case management. The incumbent should have working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, medical, etc.). The applicant should have the demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking, and problem-solving skills, ability in planning, organizing, conflict resolution, and negotiating skills. Computer literacy skills required. Weekend rotation in the emergency department required. Travel may be required to all facilities within the San Diego service area.

Required Schooling / Training

Bachelor degree in nursing or a health care related field preferred.

Who is the client company

The client is an integrated managed care organization in the United States.
If you are interested in this position, send your resume to apply@kochdavis.com