Summary:
The Access Case Manager evaluates the medical necessity for admission status. Assesses for transition Planning, and other measures for safe discharge to appropriate level of Care. Coordinates post hospital care when necessary
Essential Functions:
1. Initial patient screening
- Identifies high risk patients through rounding and referrals from ED and admitting physicians, surgical services, nurses, hospitalists, ED patients and families, and other mechanisms as appropriate.
- Uses ED tracking system, medical record, and demographic information to identify patients needing CM intervention
- Identify patients with frequent ED visits
- Identify patient returning to ED within 2 - 3 days
- Document according to policy
2. Utilization review
- Screens all patients who meet medical necessity
- Works with the admitting physician and admissions to ensure admission to the appropriate status (ie: inpatient, observation, outpatient in a bed), and level of care (ICU, telemetry, etc.) using InterQual or approved criteria.
- Educates community based and ED physicians and staff to understand admission status and appropriate patient placement and other regulatory requirements.
- Reviews surgical schedules to ensure appropriate status for surgical patients.
- Reviews all transfers-in for appropriateness of admission and intervenes as necessary.
- Escalates to physician advisor when unable to resolve issues with the attending physician, according to policy and timeframes established.
- Preadmission hospital issued notice of non-coverage (HINN) for Medicare patients per physician advisor determination and Medicare guidelines, when medical necessity criteria are not met.
- Documents according to policy.
- Case Managers who provide care to Joint Replacement patients will receive 1 hour of ortho/joint replacement specific education yearly.
3. Care coordination and patient flow
- Initiates the Care Coordination Assessment for select patients.
- Facilitates communication and information to all stakeholders.
OTHER RESPONSIBILITIES: As assigned
SUPERVISORY RESPONSIBILITIES: None.
EDUCATION, KNOWLEDGE, SKILLS, ABILITIES AND EXPERIENCE:
- Organization, analytical, writing, and interpersonal skills.
- Dependable, self-directed, and pleasant.
- Critical thinking, problem solving and deductive reasoning skills.
- Recent hospital experience preferably ICU, CCU, or strong minimum 3 years Med/Surg. Experience.
- Knowledge of Pathophysiology and Disease Process.
- Knowledge of Medicare, Medicaid, and Managed Care Health Plans.
- Experience in Hospital Case Management preferred.
LICENSES AND CERTIFICATIONS:
- Associate degree Nursing required.
- Bachelor’s degree in nursing preferred
- ACMA, CCM Preferred.
- Current American Heart Association BLS required.
Skills Required
- Two to five years of diversified, progressive experience in acute care and/or continuum of care
- Utilization review or discharge planning experience
- Bilingual English and Spanish
- Bachelor's Degree in Nursing, medicine, or related field
- Certification in Case Management (CCM) or comparable certification
- Current AHA Basic Life Support (BLS) certificate
- Experience with EMR systems (e.g., Cerner) and completing assessment screens in EMR
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.
