Inpatient Case Manager, RN
Company: Prospect Medical
Posted on: January 16, 2020
Inpatient Case Manager, RN
Prospect Medical Systems - CA
Inpatient Case Manager, RNWe are hospitals and affiliated medical
groups, working closely together for the benefit of every person
who comes to us for care. We build comprehensive networks of
quality healthcare services that are designed to offer our patients
highly coordinated, personalized care and help them live healthier
lives. Through collaboration, we strive to provide all of our
patients and medical group members with the quality, affordable
healthcare they need and deserve.
Responsible for coordination of daily inpatient services including
assessments, treatment planning, monitoring, evaluation,
documentation and discharge planning function in accordance with
Prospect Medical Group policies, procedure and processes. Interacts
with the Medical Directors and hospitalists on a daily basis to
determine necessity of continued stay.Job
- Effectively manage patients either telephonically or onsite
during their hospitalization to ensure the appropriate level of
care is provided for the patient's severity of illness. Utilizes
the appropriate tests and diagnostics in the right facilities to
facilitate the highest level of care in the most efficient manner.
Communicates effectively with facility staff and hospitalist to
gather clinical information through verbal and written
communications, and provides timely and accurate responses to
request information or provide authorization decisions.
- Interacts with hospitalists and patients daily to evaluate plan
of care including discharge planning to determine that patients are
receiving quality care and appropriate discharge disposition.
Applies medical knowledge to authorize outpatient services as an
alternative to hospitalization when appropriate. Arranges for
transfer to in-network care when appropriate.
- Updates clinical information in the electronic medical
management record system with treatment plan, objectives, results
and next steps. Documents all information accurately.
- Initiates and continues direct communication with health care
providers involved with the care of the member, including the IPA
or Hospitals Group if applicable, to obtain complete and accurate
information. Applies appropriate benefits.
- Anticipates and initiates discharge planning within twenty four
hours (24 hours) of admission, completes post discharge call within
24 hours to identify barriers and prevent readmission. Identifies
post discharge care needs and refer to the appropriate outpatient
programs and/or providers.
- Utilizes current approved criteria along with clinical
experience to make authorization decisions. Identifies cases not
meeting criteria and provides clinical information and rationale to
the Medical Director for review and determination.
- Actively participates in daily rounds with current and accurate
clinical information. Prepared to discuss current treatment plans
from the Hospitalists or Specialists, plan of care for discharge
disposition and continuity of care.
- Effectively manage an average census of 20-25 patients at any
- May be required to take After Hours On-Call pager coverage as
- Refers cases to the Medical Director as appropriate for denial
of stay or review of potential observation status.
- May be responsible for timely development of denial letter
language and member/provider notification regarding Medical
Director's review determination.
- Identifies and refers cases appropriately for CCS, High Risk,
Homebound, Hospice/Palliative, SNF, QI and Health Education, per
policy, and documents referral in case file. Actively participates
in internal quality and work flow enhancement projects, and other
duties, as assigned. Identifies and reports departmental
operational issues and resource needs to the appropriate identifies
and reports under and over utilization of medical services, delays
in service by provider or hospital or treatment and quality of care
issues to the Medical Director.
QualificationsMinimum Education: High School graduate required;
Associate in Arts degree preferred.
Minimum Experience: Three to five (3-5) years experience in a
medical group or Health Plan setting with strong clinical skills
and critical thinking. A t least 4 year's of concurrent review
experience, preferably in a managed care setting. Experience with
Microsoft Office Word (50 WPM).
Req. Certification/Licensure: RN active unrestricted
license.Employee Value PropositionProspect Medical Holdings, Inc.,
is guided by a diverse and highly experienced leadership core. This
group maintains the vision that has made Prospect a needed
difference-maker in the lives of so many patients today, and many
executives contribute to our continued efforts. As a member of our
highly effective team of professionals you will receive:
- Company 401K
- Medical, dental, vision insurance
- Paid time-off
- Life insurance
Prospect Medical Systems has a zero-tolerance policy regarding the
use of drugs and alcohol. Our Company is committed to maintaining a
productive, drug free workplace that keeps employees and patients
safe from harm. For this reason, we require applicants to pass a
screening for drug use as a condition of employment. This includes:
alcohol, marijuana, cocaine, opiates and methamphetamines.How to
ApplyTo apply for this role, or search our other openings, please
visit http://pmh.com/careers/ and click on a location to begin your
journey to a new career with us!
We are an Equal Opportunity/ Affirmative Action Employer and do not
discriminate against applicants due to veteran status, disability,
race, gender, gender identity, sexual orientation or other
protected characteristics. If you need special accommodation for
the application process, please contact Human Resources.
EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm
Keywords: Healthcare Management, Quality assessment, Utilization
review, Discharge planning, Social Service, Infection control, Risk
Management, Quality improvement, Management, Client Advocacy,
Supervisor, Registered Nurse, Acute Care
Keywords: Prospect Medical, Orange , Inpatient Case Manager, RN, Executive , Orange, California
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