BRIEF SUMMARY: Coordinates, negotiates, procures, and manages the care of complex patients to facilitate achievement of quality, cost-effective patient outcomes; works collaboratively with the interdisciplinary team, internal and external to the organization; participates in quality improvement and evaluation processes related to the management of patient care.
ESSENTIAL FUNCTIONS:
1. Conducts admission and concurrent utilization activities according to established criteria and guidelines (MCG, InterQual).
2. Assesses the multidimensional domains of physical, psychosocial, and emotional functioning & supports, and financial resources of the patient.
3. Identify need for case management services at multiple points within the health care continuum.
4. In collaboration of all members of the health care team including the patient and/or decision makers plans for high quality, realistic, and cost-effective/resources driven continuum of care arrangement for identified patients.
5. Makes appropriate referrals using available community/regional resources.
6. Develops a network of the usual services and disciplines required by patients.
7. Maintains a working knowledge and application of the requirements of payers most frequently seen within the population.
8. Complies with all payers’ contracts/programs including denial and appeal procedures.
9. Referrals to the next level of care will include direct communication with the facility representative.
10. Facilitates the transfer of necessary documents/data with the patient to the next level of care.
11. Concurrently analyzes variances from expected outcomes to determine need for action.
12. Collaborates with all members of the health care team to document patient status and variances, working toward achievement of patient goals/optimum quality and cost outcomes.
13. Maintains complete and disciplined documentation of Case Management activities.
14. Provides leadership by enhancing understanding of the integrated Case Management Process with all members of the health care team.
15. Conducts discharge planning interviews and completes appropriate assessment screen in EMR ( Cerner etc)
OTHER RESPONSIBILITIES:
1. Engages in emergency, fire, and disaster drills.
2. Demonstrates ability to care for and maintain equipment appropriately.
3. Attends mandatory classes as required
4. Attends required staff meetings.
5. Is punctual and prompt for work: (3 times in 30 days is excessive).
6. The policies and procedures for sick and unscheduled absences are followed.
7. Adheres to PMH dress and grooming standards policy.
8. Completes in-services and health exams as required by accrediting agency, Department of Public Health and PMH.
9. Extends courtesy and congeniality.
10. Ensures confidentiality and adheres to the privacy act.
11. Assumes other responsibilities as assigned.
SUPERVISORY RESPONSIBILITIES: None
EDUCATION, KNOWLEDGE, SKILLS, ABILITIES AND EXPERIENCE:
1. Two to five years of diversified, progressive experience in acute care and/or other settings within the continuum of care.
2. Utilization review of discharge planning experience preferred
3. Bilingual English and Spanish preferred
LICENSES AND CERTIFICATIONS:
1. Bachelor’s Degree in Nursing, medicine, or related field.
2. Certification in Case Management (CCM) or comparable certification preferred.
3. Current AHA Basic Life Support certificate required.
AGE OF POPULATION SERVED:
Newborn __ Infant/Pediatric __ Adolescent __ Adult __ Geriatric _X_ All No Patient Care__
PHYSICAL REQUIREMENTS:
Position requires critical decision making involving multiple variables which determine/influence quality and cost outcomes for the patient and the system. Position requires ability to frequently push/pull/lift light objects less than 20 pounds, perform moderately difficult manipulative, arm-hand steadiness, and eye-hand coordination skills; walk and stand; see objects closely and hear normal sounds with some background noise. Position requires ability to concentrate on fine detail, with constant interruptions and attend to tasks or functions for 10-20 minutes at a time. Individual must be able to understand and relate to theories behind several related concepts, remember multiple tasks given over long periods of time, and be able to communicate in written word using advanced written skills.
Skills Required
- Two to five years of diversified, progressive experience in acute care and/or continuum of care
- Bachelor's Degree in Nursing, medicine, or related field
- Current AHA Basic Life Support (BLS) certificate
- Experience with EMR systems (e.g., Cerner) and completing assessment screens in EMR
- Utilization review or discharge planning experience
- Certification in Case Management (CCM) or comparable certification
- Bilingual English and Spanish
What We Do
Pioneers Memorial Healthcare District, an Affiliate of the Scripps Health Network is proud to be the only ISO 9000:2008 certified hospital in the County of Imperial. ISO 9000:2008 certification is an international signal of our dedication and commitment to protecting our patients’ health and safety while they are with us. Located in Southern California, Pioneers Memorial Hospital is a highly recognized, 107-bed, acute care facility accredited by DNV - which stands for Det Norske Veritas – the Nordic Truth, is a hospital accreditation organization approved by the U. S. Center for Medicare and Medicaid (CMS) and has some of the most strenuous standards in healthcare. We are committed to providing state-of-the-art healthcare and the highest quality community education. Located in Imperial Valley in southeastern California, Pioneers opened our doors in 1950. From the very beginning, we have been committed to continually updating, upgrading and improving our facility and our care. We have invested in technological advancements not commonly found in a hospital of our size. We offer a modern 16-bed emergency facility. We are a level 4 trauma center with an excellent reputation and board-certified emergency physicians. We offer specialized treatment through our Cancer Institute, Wound Clinic, Joint Replacement, Physical Therapy Center, Pioneers Health Center and Calexico Health Center. Within the Phyllis Dillard Family Medical Center is a duo surgery suite for obstetrical and gynecological surgeries. There are 14 suites in our Perinatal Department within the Women’s Center and we deliver approximately 1,800 babies per year.
