Case Mgr Utilization RN Job in Fontana, California Us

Works collaboratively w/ an MD to coordinate screen for the appropriateness of admissions and continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpt hospitalization. Interacts with the family, patient other disciplines to coordinate a safe acceptable discharge plan. Functions as an indirect caregiver, patient advocate manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities.
Essential Functions:
- Plans, develops, assesses evaluates care provided to members.
- Collaborates w/ physicians, other members of the multidisciplinary health care team patient/family in the development, implementation documentation of appropriate, individualized plans of care to ensure continuity, quality appropriate resource use.
- Assesses high risk patients in need of post-hospital care planning.
- Develops coordinates the implementation of a discharge plan to meet patient's identified needs; communicates the plan to physicians, patient, family/caregivers, staff appropriate community agencies.
- Reviews, monitors, evaluates coordinates the patient's hospital stay to assure that all appropriate essential svcs are delivered timely efficiently.
- Participates in the Bed Huddles carries out recommendations congruent w/ the patient's needs.
- Coordinates the interdisciplinary approach to providing continuity of care, including utilization mgmt, transfer coordination, discharge planning, obtaining all authorizations/approvals as needed for outside svcs for patients/ families.
- Conducts daily clinical reviews for utilization/quality mgmt activities based on guidelines/standards for patients in a variety of settings, including outpt, ER, inpt non-KFH facilities.
- Acts as a liaison between inpt facility referral facilities/agencies provides case mgmt to patients referred.
- Refers patients to community resources to meet post-hospital needs.
- Coordinates transfer of patients to appropriate facilities; maintains provides required documentation.
- Adheres to internal external regulatory accreditation requirements compliance guidelines including but not limited to: JCAHO, DHS, HCFA, CMS, DMHC, NCQA DOL.
- Educates members of the healthcare team concerning their roles responsibilities in the discharge planning process appropriate use of resources.
- Provides patients w/ education to assist w/ their discharge help them cope w/ psychological problems related to acute chronic illness.
- Reviews, analyses identifies utilization patterns trends, problems or inappropriate utilization of resources participates in the collection analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
Qualifications:
Basic Qualifications:
- Minimum two years clinical experience as an RN in an acute care setting required.
- Bachelor's degree in nursing or healthcare related field preferred or current equivalent related work experience.
- Graduate of an accredited school of nursing required.
- Current and valid California RN license required.
- Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of utilization review/management, discharge planning and case management.
- Working knowledge of regulatory requirements and accreditation standards (JCAHO, Medicare, Medi-Cal, etc.).

Preferred Qualifications:
- 2 years Case Mananger experience.
- Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem-solving skills.
- Demonstrate ability to utilize written and verbal communication, interpersonal, critical thinking and problem solving skills.
- Collaborates with and provides direction to the physician, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use.
Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities.
- Independently identifies and assesses high-risk patients in need of post-hospital care and follow-up, using UM criteria, guidelines, high risk screens, clinical judgments, etc as appropriate.
- Able to multi-task in a fast paced environment.
- Trainable for various in-house computer systems