Care Manager II, Acute (RN)

Organization:

Bay Administration

Position Overview:

Responsible for Care Coordination and Care Transitions Planning throughout the acute care patient experience. This position works in collaboration with the Physician, Utilization Manager, Medical Social Worker and bedside RN to assure the timely progression and transition of patients to the appropriate level of care to prevent unnecessary admissions or readmissions. The Care Management process encompasses communication and facilitates care across the continuum through effective resource coordination. The goals of this role are to include the achievement of optimal health, access to care, and appropriate utilization of resources balanced with the patients' self –determination while coordinating in a timely and integrated fashion. He/She collaborates with patients, families, physicians, the interdisciplinary team, nursing management, quality, ancillary services, third party payers and review agencies, claims and finance departments, Medical Directors, and contracted providers and community resources. If assigned to the Emergency Department, the Care Management process is to address complex clinical and social situations efficiently in order to avoid unnecessary admissions.

Job Description:

These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

JOB ACCOUNTABILITIES:

Patient Initial and Continued Assessment.
• Reviews initial physician admission care plan. Gathers additional medical, psychosocial, and financial information from the patient/family interview, medical record assessment, physicians, and other health care providers. Determines moderate or high risk level for readmission. Conducts a screening for ancillary supportive services, including but not limited to Palliative Care Services’ needs.
• Functionally supervises and actively leads the health care team in developing comprehensive cost-effective care coordination plans that meet the clinical needs of our patients.
• Identifies and refers quality and risk management concerns to appropriate level for patient safety reporting and trending.
• Directs and oversees the Case Management Assistants to determine preferences for post-acute care services.


Utilization Management.
• Reviews medical record to ensure patient continues to meet level of care (LOC) requirements and that chart documentation supports LOC determination and assignment.
• Works with Attending Physicians to confirm necessary documentation to support level of care (LOC).
• Expedites transition planning for patients who no longer require acute level of care.
• Monitors length of stay (LOS) and outliers requiring additional resources and/or focus.
• Collaborates with financial counselor for delivery of inpatient stay denials.
• Assures delivery of Medicare Important Message within 48 hours of discharge/transition and no less than 4 hours of actual discharge/transition.
• Actively participates in patient rounds following the standard work as developed and collaborates with interdisciplinary team to assure timely transition.
• Follows policies and procedures for Physician Advisor referrals.
• Utilizes appropriate escalation process when discussing level of care (LOC) requirements with providers.
• Consistently documents in the EHR and other electronic software.
• Maintains current knowledge of CMS and Joint Commission Transitions of Care requirements, Conditions of Participation (COPs), and other regulatory requirements.
• Effectively follows Observation patients, re-evaluates and collaborates with attending physician for admission or transition to appropriate level of care for the patient.


Care Coordination/ Care Transitions.
• Formulates a transition plan after reviewing available/appropriate care options and obtaining input, and collaborating with the patient/family and physician, health care team, payers, and community based support services.
• Performs, documents, and communicates assessment findings to health care team.
• Screens 30-day readmissions; reviews previous hospital record confers patient/family and with interdisciplinary team to create an effective and realistic transition plan.
• Proactively identifies barriers to care progression and transition, and works with multi-disciplinary team to resolve timely.
• Addresses complex clinical and social situations efficiently in order to avoid unnecessary admissions, improper level of care utilization, and delays in transition. Reviews and modifys plan of care.
• Assures timely transition to lower level of care.
• Assesses the need for follow up appointments and when applicable communicates to patient/family prior to transition.
• Assures necessary paperwork for post-acute transfers to comply with state and federal regulatory requirements.
• Identifies ED high utilizers and makes appropriate care plans and referrals to community resources.
• Identifies patient and families with complex psychosocial issues (social determinants of health) and refers to health care team as appropriate.
• Communicates with Financial Counselors regarding uninsured, underinsured and makes referrals, as appropriate.
• Makes appropriate and timely referrals and completes documentation to comply with state and federal regulatory requirements.
• Identifies patients appropriate for case management intervention by reviewing the electronic health record (EHR) and meeting with patients and collaborating with staff and physicians.
• Follows locally determined resources and workflows for patient transfers.


Actively participates in ongoing department operations.
• Identifies new system, processes, protocols and/or methods to improve practices.
• Actively contributes to the creation of cost effective practices that ensure the best patient/provider experience, effective resource utilization, and safe outcomes.
• Effectively communicates with Care Management colleagues for safe transitions.
• Actively aware and manages all communications (email, KDS, Policies & Procedures, Handoffs, and other) and participates in all department meetings.


Uses effective interpersonal and communication skills to promote customer service with internal and external customers.
• Develops and maintains positive, productive, and professional relationships with the healthcare team and representatives of community agencies.
• Relates with tact and respect to all customers with diverse cultural and socioeconomic backgrounds without personal judgment.
• Be a positive participant, actively engaged in all department operations.
• Willingly provides and accepts direct, constructive feedback to and from colleagues and the leadership team. Actively uses effective communication skills with colleagues to resolve issues in a timely manner.



EDUCATION:

Graduate of an accredited school of nursing


CERTIFICATION & LICENSURE:

RN-Registered Nurse of California Upon Hire


TYPICAL EXPERIENCE:

2 years recent relevant experience.

SKILLS AND KNOWLEDGE:

A broad knowledge base of health care delivery and case management within a managed care environment.

Comprehensive knowledge of Utilization Review, levels of care, and observation status.

Awareness of healthcare reimbursement systems: HMO, PPO, PPS, CMS, value-based reimbursement models, and alternative payment systems preferred.

Working knowledge of laws, regulations, and professional standards affecting case management practice in an integrated delivery system: including but not limited to: CMS, Title 22, CHA Consent Manual, CDPH and TJC.

A broad knowledge base of post-acute levels of care and associated regulatory compliance requirements.

General understanding of coding and DRG assignment process preferred.

Must be able to effectively communicate with, and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners.

Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.

Demonstrates commitment to service excellence in all patients, family and employee interactions and in performing all job responsibilities.

Functions in a manner to promote quality patient care and assure a positive patient experience.

Strong verbal and written communication skills and negotiation skills

Must have excellent time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.

Intermediate computer and technology skills.

Ability to promote teamwork and to effectively function in teams.

Ability to interact effectively with key internal and external constituents using collaboration, and customer service skills that promote excellence in the patient experience.



PHYSICAL ACTIVITIES AND REQUIREMENTS:

See required physical demands, mental components, visual activities & working conditions at the following link: Job Requirements

Job Shift:

Days

Schedule:

Part Time

Shift Hours:

8

Days of the Week:

Variable

Weekend Requirements:

As Needed

Benefits:

Yes

Unions:

No

Position Status:

Non-Exempt

Weekly Hours:

36

Employee Status:

Regular

Number of Openings:

1

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $79.37 to $104.76 / hour

Qualified applicants with arrest and conviction records will be considered for employment. Applicants for specific positions are still required to disclose certain convictions during the application process, and those convictions may also be considered in determining eligibility for employment in accordance with applicable law.

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