Job Description

Summary

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

• Screens calls for admissions against Milliman Care Guidelines (MCG) to determine if member required Observation admissions vs Inpatient admission to the acute care setting
• Facilitates patient’s transfer to capped hospital when admitted to an out of network or out of capped facility and needs continued hospitalization within 24 hours of admission.  The nurse follows the Out of Network Transfer Protocol below:
  • The nurse calls the assigned hospitalist where the patient is to be transferred to and lets him/her know that the current attending physician will be calling to discuss continuation of care or vice-versa.
  • The nurse calls the capitated hospital to check if bed is available, provides patient’s demographic information and faxes a face-sheet or pertinent records to the hospital if requested.
  • The nurse checks if MD-to-MD has occurred and once confirmed that the hospitalist has accepted the patient’s transfer and if bed is available, the nurse generates a tracking number for the ambulance. 
  • The nurse calls the facility where the patient is being transferred from in order to give the room number assigned for the patient, the phone number for the nurse’s station where the releasing hospital has to call for report and gives the authorization generated for the ambulance. 
• Facilitates Emergency Room (ER) transfers when patients require admission.   The nurse assesses and verifies if the patient is stable for transfer to capped hospital, if stable will proceed to Step 1a.  If unstable or no bed is available, the nurse gives authorization to admit the patient
• Documents the specific reason/s why patient is not repatriated back into network or capped facility.
• Verifies if the attending physician assigned on the case is the correct hospitalist. If assigned attending is not the correct hospitalist, the nurse switches the providers by calling the contracted hospitalist on the case, once accepted, the nurse informs the attending provider that IPA contracted hospitalist will be taking over the case.  The nurse e-mails Provider Relations Department of the incorrect attending physician assignment for hospital ER and admitting staff education to ensure correct Hospitalist assignment on future admissions.
• Coordinates transfers of patients to tertiary facilities for higher level of care
  • Refer to higher level of care workflow
• Calls the hospital UR Department to request initial reviews, concurrent reviews and discharge planning for IPA members.
• Documents clinical reviews in the EZ-cap system.
• Assigns the appropriate Level of Care (LOC) and approves the authorization if deemed medically necessary using MCG or Health Plan required guidelines 
• Identifies unnecessary or aberrant days and forwards the information to the Medical Director and Inpatient UM Manager for final review and determination of potential denial of days.
• Forwards the case to the Notice of Action (NOA) Coordinator for denial or modification letter generation if final determination is to DENY or modify continued stay. 
• The nurse ensures that the case is closed accurately and documents ADMIT TYPE, ADMIT SOURCE, PATIENT STATUS on the Auth Details Field within the required ICE TAT.
• Provides authorization for discharge needs i.e. home health care PT, OT, skilled nursing visits, Home infusion, Self-injectable drugs, DME, medical supplies, etc.
  • For IPA’s where the nurse is delegated for Discharge Coordination
• Reviews and documents clinical reviews of SNF patients at least weekly.
  • For IPA’s where the nurse is delegated to follow SNF admissions 
• Forwards to Realignment team/ Member Liaisons information of SNF patient who is admitted to long-term care and has resided in a nursing facility beyond 30 days after the month of admission to facilitate disenrollment of member from managed Care Medi-cal back to Fee for Service Medi-cal.
• Provides authorization for inter-facility ambulance transfers.
• Attends the daily inpatient meeting to go over daily bed day reports with the Medical Directors.
• 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 potential re-admissions to Outpatient High Risk Case Management (SPD, SNP, CMC) or Readmission Teammates (non-SPD, non-SNP, non-CMC) for follow-up post discharge. 
• Refers any potential quality of care issues (PQI) identified to the QI Department for review of QI cases. 
• Provides coverage as needed.

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.

Skills 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.

Salary Range:

• $38 - $42 per hour

Job Tags

Similar Jobs