Inpatient Senior Nurse Case Manager

Provides overall coordination in the delivery of medical services and discharge planning for a specified patient population.  Performs concurrent review of patient medical records for purposes of utilization review, compliance with requirements of external review agencies including governmental and non-governmental payers and quality assurance agencies.  Promotes a cooperative and supportive relationship as liaison with patient, family, facility staff, physicians, funding representatives and community agencies.  Ensures continuity in the handoff of patient clinical information from the hospital to other involved healthcare entities. 

Duties and Responsibilities

·         Responsible for all Duties & Responsibilities in the Inpatient Nurse Case Manager job description.

·         Provides coverage as needed and follows concurrent policies, procedures, and workflow.

·         Attends the daily inpatient meeting to go over daily bed day reports with the Medical Directors. Assists Lead/Supervisor on huddle as needed.

·         Reviews and maintains bed day logs weekly and monthly to ensure that Status “I” Or pending/open cases are closed timely.

·         Notifies Lead/Supervisor the number of open cases daily.

·         Refers any potential quality of care issues (PQI) identified to the QI Department for review of QI cases.

·         Assists Lead/Supervisor on Health Plan request / DMHC request / Grievance

·         Assists Lead/Supervisor on any reporting as needed (eg. Scrubbing, health plan ad hoc report, client ad hoc report)

·         Assists Lead/ Supervisor in tracking hospital cap opportunities and escalates timely.

·         Assists Lead/ Supervisor on tracking and reporting High Acuity cases

Minimum Job Requirements

·         Current RN or LVN licensure; Preferred: BSN level of education.

·         Registered Nurse or Licensed Vocational Nurse with clinically focused work history.

·         Prefer three-five years clinical experience within an acute health care setting with recent work history in acute care case management role or related health care experience. 

·         Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review/quality assurance, use of Milliman or other clinical decision support criteria, discharge planning, and reimbursement structures (i.e., Government and non-governmental payers).

·         Ability to read, analyze and comprehend complex clinical data and its application to level of care criteria and discharge options; strong, broad-based clinical knowledge and understanding of pathology/physiology of disease processes; excellent critical thinking skills; assertive personality traits to facilitate ongoing physician communication; organize, prioritize, and manage time efficiently.

Skill and Abilities

·         Computer literacy and familiarity with the operation of basic office equipment.

·         Must be able to communicate effectively with a wide range of hospital personnel, physicians, patients/family members within various socioeconomic groups and representatives of varied outside agencies.