FierceHealthcare Jobs
LVN - Telephonic Case Manager - Medical Professionals
Jan 12
Location: Cerritos, CACategories: Nurse
Website: http://mypsr.com
Position Description
Summary
The Case Management Nurse, under the direction of the Medical Director, is responsible for: 1) day to day case management of both inpatient and outpatient cases, 2) maintaining statistics on inpatient and outpatient processes, and 3) promoting quality patient care outcomes while supporting appropriate utilization/resource management along the continuum of care.
Essential duties and responsibilities include, but are not limited to:
1. Conducting ongoing telephonic review of inpatient cases (i.e., acute, subacute, skilled, behavioral health) for direct members in non-delegated & delegated groups.
2. Ensuring that discharge planning is conducted in a timely manner.
3. Reviewing/Approving outpatient referrals meeting criteria and making case presentations on referrals that do not meet criteria for approval to the Medical Director.
4. Notifies the appropriate individuals when members meet stop-loss criteria or there may be a third party liability issue.
5. Reviews claims when the pre-service/concurrent review was not performed (for direct and non-delegated & delegated group members).
6. Maintaining case management for members receiving home health services for direct and non-delegated & delegated groups.
7. Reviews and processes Health Risk Assessments and appropriately forwards high risk members to case management.
8. Ensures health education resources are available for direct and members in non-delegated groups.
9. Collaborates with the Medical Director for health education purposes, when applicable
10. Tracks continuity of care issues identified through the enrollment process, and resolves when identified.
11. Tracks members enrolled in hospice and ESRD and transplant members and notifies IPA/MGs, when applicable.
12. Ensures compliance with the NOMNC process when SNF, HHA, or CORF services are terminated by coordinating with the IPA/MG and/or facility.
13. Maintaining case management records according to policy.
14. Interfacing with primary care physicians, specialty care physicians, mental health professionals, home health professionals and other health care professionals regarding patient care.
15. Maintaining confidentiality of information between and among health care professionals.
16. Assisting with the review and development of new protocols, procedures and guidelines.
17. Maintains confidentiality of information between and among health care professionals.
18. Other duties as requested or assigned.
Supervisory Responsibilities
This individual has no supervisory responsibilities.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Education and/or Experience: Successful completion of an accredited Licensed Vocational Nurse or Registered Nursing Program; two to three years related experience in a managed care setting
2. Certificates, Licenses, Registrations: Current, Active and Unrestricted California Licensed Vocational Nurse or Registered Nursing license
3. Other Qualifications:
a. Knowledge of Medicare Managed Care Plans
b. Computer Skills: Word, Excel, Microsoft Outlook
c. Experience with the application of UM criteria (i.e., Apollo, CMS National and Local Coverage Determinations, etc.)
d. Bilingual (English/Spanish)
e. Be able to handle up to 40 cases at a time
