Providence RN Inpatient Case Manager in Mission Hills, California
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Providence is calling a RN Inpatient Case Manager (Per Diem Shift) to Providence Facey Medical Foundation in Mission Hills, CA.
We are seeking a RN Inpatient Case Manager who will be responsible for utilization review and discharge planning for capitated patients who are hospitalized. The review includes coordination of services for medical necessity, cost effectiveness, timelines of service and ensuring that quality standards are met. Performs coordination of services for patients whose health plan has an at-risk agreement to ensure that services are medically necessary, cost effective, provided in a timely manner and meet local standards or care.
In this position you will:
Act as a resource for case management activities:
Deliver upon the service expectations of both our patients and fellow staff members by listening to their needs; engaging in positive interactions; and following through on expectations made in a thoughtful, efficient, timely and courteous manner so that their total outcome is better than expected.
Respect the dignity, confidentiality and privacy of patients.
Work in a safe manner, adhering to general safety precautions and standards. Reports any unsafe conditions to their supervisor and/or the safety hotline.
Perform concurrent review on hospitalized patients in network and all out of network acute facilities and Skilled Nursing Facilities. Works collaboratively with the hospital based physician and under the direction of the MD UM.
Review referral requests for ambulatory patients for medical appropriateness based on health plan and other clinical guidelines adopted by the Providence MSO.
Utilize all reference materials to identify appropriate and contracted referral targets, including the EMR, internet rosters and reference materials.
Refer cases not meeting criteria for medical necessity to MD UM Chair/Medical Director. Advise appropriate medical group or insurer when acute care is no longer medically necessary so that denial letters may be issued.
Review hospitalized patients with the Medical Director and/or UR chairperson as requested.
Assist with review and processing of the UR requests.
Attend weekly CM meetings, monthly CM Staff meetings and other meetings as assigned.
Maintain records and statistics as required, i.e. - bed days, discharges, re-admissions, diagnoses.
Coordinate transfer of “out-of-area” patients into network hospitals, when indicated with documentation in EPIC.
Refer cases to California Children Services as appropriate for additional coverage and services.
Maintain confidentiality of all patient and Utilization Management information.
Perform Discharge Planning/Case Management activities:
Perform concurrent review of hospitalized patients and formulates discharge plan/case management within two working days of admission.
Implement discharge plan/case management and makes appropriate referrals to Home Health Agencies, Skilled Nursing Facilities, Board and Care Facilities, Hospice Care, etc. Works closely with the discharge planners at appropriate hospital to facilitate timely transfer or discharge.
Arrange placement of patients in facilities that are appropriate for their level of care requirements.
Acquire authorization to Skilled Nursing Facilities, durable medical equipment and home health care when medically necessary, included in the patients’ health plan benefits.
Make regular visits to contracted Skilled Nursing Facilities or assigned hospitals as assigned; to ensure that services provided are medically necessary and meet the standards of care.
Refer appropriate cases to Social Services for psycho-social intervention. Refers appropriate cases for Medi-Cal and California Children Services and/or agencies.
Maintain accurate and thorough documentation of discharge planning/case management activities on the patient’s medical record as well as Utilization Management worksheets.
Work collaboratively with other members of the health care team as well as the respective medical groups to facilitate the Utilization Management process.
Identify and refer situations needing immediate intervention to Administrative Director of Managed Care, UM RN Manager, MD UM Chair, Medical Director, Quality Assurance and Risk Management, as appropriate.
Participate in UM Department and Quality Assurance program and projects as needed.
Maintain documentation in patient EHR as needed and guided by policy.
Review high risk and re-admission cases, maintains complete documentation in EHR of telephonic case management on these patients.
Follow-up on discharged patients by telephone as necessary to ensure delivery of medical equipment, home health visits and assesses health status.
Maintain a high degree of professionalism:
Demonstrate the ability to make decisions, take appropriate action and follow tasks through to completion.
Recognize and analyze the implications of new situations and develops workable solutions to maintain productivity and morale.
Act as a role model in demonstrating the customer service standards of the organization.
Demonstrate a commitment to personal growth and development by participating in external activities related to professional goals.
Respond cooperatively to managers and staff members in other departments to promote teamwork.
Attend departmental meetings as appropriate and contributes ideas for improving efficiency, productivity and patient satisfaction.
Demonstrate behaviors which are consistent with the Code of Conduct and aligned with the organization's mission, vision and shared values:
Report promptly any suspected or potential violations to laws, regulations, procedures, policies and practices, and cooperates in investigations.
Conduct all transactions in compliance with all company policies, procedures, standards and practices.
Demonstrate knowledge of all applicable compliance and legal requirements of the job based on the scope of practice of the position.
Ensure that appearance and personal conduct are professional at all times:
Excellent attendance record.
Wear appropriate clothing for job functions.
Work at maintaining a good rapport and a cooperative working relationship with physicians, health plans and staff.
Represent the organization in a positive and professional manner in the community.
Maintain organizational and patient confidentiality at all times.
Must be able to physically ambulate within a designated facility or more than one facility per day, as assigned.
Required qualifications for this position include:
RN graduate of an accredited school of nursing.
Current, unrestricted, California RN license
American Heart Association BLS for Health Care Providers
2 years current acute med/surg experience
Will act under the oversight of an RN Supervisor/Manager/Director.
Basic knowledge of disease processes, ability to prioritize medical conditions and to use effective nursing judgment in problem solving.
Demonstrates proper phone etiquette, strong computer skills including knowledge of Word and Excel.
Excellent communication skills, must be organized and a self-starter, must have extensive knowledge of health plan requirements and benefits as applied to the utilization and case management process.
Preferred qualifications for this position include:
hospital inpatient case management or ambulatory case management experience
About the ministry you will serve:
Facey Medical Group is a multi-specialty medical group with over 160 physicians providing care to the growing population in the North & East regions of Los Angeles & Ventura Counties. Twelve medical clinics, including two urgent care centers and dedicated women's centers, are located across the San Fernando, Santa Clarita and Simi Valleys. The group began as a single medical practice over 90 years ago. Facey is now part of Providence Health & Services, an integrated, not-for-profit 5-state network of hospitals, care centers, medical clinics, affiliated services and educational facilities spanning from California to Alaska.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Case Management
Location: California-Mission Hills
Req ID: 296562