Job Summary
Provides case management services to a caseload of low- and medium-risk patients. Interviews patients and their caregivers to evaluate needs, goals, and current services. Proposes process improvements for determining initial eligibility, benefits, and education for all admissions, leveraging advanced knowledge to assess medical necessity and required level of care to inform physicians. Analyzes and ensures authorization data and escalates inaccuracies. Develops a client-focused case management plan in collaboration with healthcare team, patient, and caregivers that is consistent with regulatory, accreditation, and regional guidelines. Assists patients with gaining access to care based on their needs, making referrals as appropriate. Coordinates resources and services to assure continuity and quality of care. Attends case management rounds with clinician and updates authorizations and diagnoses as needed. Assesses patient progress toward treatment milestones and care plan goals. Identifies barriers to achieving goals and ensures that they are discussed with the patient and care team thoroughly. Verifies that all services remain consistent with established guidelines and standards. Documents the patients case in all medical files. Reviews benefits/services available to patients, caregivers, and other members of the community and addresses identified concerns. Connects patients and caregivers with the right entities to assist with benefits/coverage needs. Identifies patients ready for disposition planning activities. Develops and communicates a comprehensive disposition plan in collaboration with the patient, caregivers, physician, nurses, social services, and other healthcare providers and agencies. Obtains authorizations as needed for patient services. Recommends and attends professional seminars, workshops, and approved educational programs and workshops. Monitors and reviews operational team data and key metrics applied to own work. Makes suggestions for change or improvement as needed. Ensures adherence to regulatory requirements by implementing policy updates.
Essential Responsibilities
- Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.
- Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.
- Drives services related to the initial case assessment by: interviewing patients and their families to evaluate needs, goals, and current services independently; identifying and proposing process improvements for determining initial eligibility, benefits, and education for all admissions; analyzing and ensuring authorization data (e.g., authorization data regarding admitting/principle diagnoses, bed type(s), and disposition data for accuracy, after visit summary) and correcting and escalating inaccuracies; recommending and designing research plans that identify new and/or existing options to assure that quality, cost-efficient care is provided; and leveraging advanced knowledge to assess medical necessity for hospital admission and required level of care to inform physicians.
- Provides services related to monitoring and evaluating plan of care by: coordinating resources and services to assure continuity and quality of care, sharing advanced knowledge with others, and developing strategies; updating authorizations, attending case management rounds with clinicians, and updating diagnoses as needed; contacting own patients periodically to assess progress toward treatment milestones and care plan goals, and beginning to coordinate team members to do the same; identifying barriers to achieving goals and ensuring that they are discussed with the patient and care team thoroughly, and guiding team members doing the same; promoting best practices for verifying that all services remain consistent with established guidelines and standards; and documenting/updating the patients case in all medical files while sharing standards with the team.
- Drives services related to the case-planning process by: creating a client-focused case management plan with treatment goals based on the patients and familys/caregivers needs independently; collaborating independently with health-care team, patient, and caregivers to assure plan of care is safe, agreeable, and appropriate; and validating that the plan is consistent with regulatory, accreditation, and regional guidelines independently, and sharing feedback with team members as needed.
- Supports efforts to remain updated on current research, policies, and procedures by: researching, recommending, and attending pertinent seminars, workshops, and approved educational programs and workshops specific to professional needs; implementing systems, processes, and methods to maintain team knowledge of community resources; monitoring and/or reviewing operational team data and key metrics applied to own work; making suggestions for change or improvement as needed, and helping others to develop ideas as needed; and implementing policy updates to ensure that regulatory requirements are being met.
- Provides services related to patient disposition by: performing daily review for early identification of disposition planning activities; developing, evaluating, coordinating, and communicating a comprehensive disposition plan in collaboration with the patient, family, physician, nurses, social services, and other healthcare providers and agencies to meet each patients personal, psychosocial, economic, and cultural needs independently; and leveraging advanced knowledge to create, obtain, and approve authorizations/approvals as needed for services for the patient.
- Connects patients with existing services by: guiding others to assist patients with gaining access to care based on their needs, integrating or referring them into existing programs/services, and resolving moderately complex issues; referring patients independently to outside entities, ambulatory case managers, care managers, social workers, and/or internal/external resources as appropriate; utilization management for internal case management post acute care services; hospital level of care, post-acute care, skilled nursing facility (SNF), and durable medical equipment (DME), and transition and complex case management and making location-specific adaptations as necessary.
- Serves as liaison between internal and external care by: reviewing benefits/services available based on regulations or specific coverage to patients, families, and other members of the community, problem solving identified concerns, and connecting patients/families with the right entities to assist with benefits/coverage needs; providing case management to a caseload of low- and medium-risk patients referred to external facilities/agencies independently; applying strategies and concepts to independently propose recommendations in interdisciplinary team meetings with internal and/or external stakeholders; and leveraging advanced knowledge to act as a general resource for physicians, health plan administrators, and contracted vendors.
Knowledge, Skills and Abilities: (Core)
- Ambiguity/Uncertainty Management
- Attention to Detail
- Business Knowledge
- Communication
- Critical Thinking
- Cross-Group Collaboration
- Decision Making
- Dependability
- Diversity, Equity, and Inclusion Support
- Drives Results
- Facilitation Skills
- Health Care Industry
- Influencing Others
- Integrity
- Learning Agility
- Organizational Savvy
- Problem Solving
- Short- and Long-term Learning & Recall
- Teamwork
- Topic-Specific Communication
Knowledge, Skills and Abilities: (Functional)
- Acts with Compassion
- Business Relationship Management
- Community Health
- Company Representation
- Confidentiality
- Health Care Compliance
- Health Care Quality Standards
- Information Gathering
- Maintain Files and Records
- Managing Diverse Relationships
- Member Service
- Patient Safety
- Quality Assurance and Effectiveness
- Relationship Building
- Written Communication
Minimum Qualifications
- Bachelors degree in Nursing or related field AND minimum five (5) years of experience in nursing, case management, or a directly related field.
- Registered Nurse License (California) required at hire
Preferred Qualifications
- Certified Case Manager (CCM) in the state where care is provided.
- Minimum one (1) year of experience in a leadership role with or without direct reports.