Employment Status:Full Time (72-80 Hours Per Pay Period)Job Category:NursingJOB SUMMARY:All employees are expected to perform their duties in alignment with the vision and values of the organization.
The person doing this job is responsible for a variety of tasks that lead to a high level of customer satisfaction in the most cost-effective manner.
Responsible for Utilization Management, Case Management, and Discharge planning activities on designated units within the Hospital.EXPERIENCE/QUALIFICATIONS:Minimum of two (2) years case management experience in an acute setting required.
Critical Care experience desirable.
Previous experience in Utilization Management or Discharge Planning required.
Must be able to assess discharge-planning needs of a diverse cultural and ethnic population.Must be able to demonstrate the knowledge and skills necessary to provide appropriate case management specific to the age of the patients served on assigned units.
Case Managers are assigned patients ranging in age from neonates to geriatrics.
Assignments are dependent upon the specific talent, experience and training of the Case Manager and the needs of the patient.Must be able to exercise independent discretion and judgment (utilizing approved criteria) in the performance of the case management functions.Basic Microsoft computer skills required.EDUCATION:Bachelor of Science degree in Nursing is required for new hires as of October 2017LICENSURES/CERTIFICATION:Current licensure with the California Board of Registered NursingMust successfully complete and maintain LA City Fire Card certification at the time of hire or within the first 30 days of employmentDUTIES AND RESPONSIBILITIES (These are the essential job functions for this position.
The essential functions of this job include, but may not be limited to those listed in this job description.
Employees hired for this position must be able to perform the essential function of this job without imposing significant risk of substantial harm to the health or safety of themselves or others):Independently performs daily concurrent chart reviews on all assigned patients utilizing approved hospital criteria (Medi-Cal and managed care patients require daily review regardless of criteria recommendation).Proactively call/fax daily concurrent chart reviews to managed care companies (MCO)/medical groups according to payor contract/hospital policy.
Document the review was called/faxed to MCO/medical group and document the dates approved for continued stay on the review record.
Ensure MCO/medical group review call-in and approval dates are entered in the Meditech System to avoid payor denials.Respond to MCO or medical groups within 24 hours of receiving notice when concurrent or retrospective patient care reviews are requested.Independently performs timely retrospective chart reviews on all assigned patients utilizing approved hospital criteria.
Perform managed care reviews within 24 hours of notice and TAR reviews with 24 hours of notice.Discusses medical necessity/medical management issues with attending/responsible physicians and physician advisor, when indicated.Document concurrent TAR reviews daily.
Complete retrospective TARs within five (5) business days of notification.Adhere to California Children Services (CCS) care management guidelines when responsible for managing CCS patients.
Call/fax timely reviews according to CCS guidelines.Document the medical necessity criteria page number and next review date on review records.Refers cases not meeting criteria (including situations involving the timely provision of services) to Physician Advisor or Medical Director as appropriate.Obtains authorizations as required by third party payors for patients whose insurer has such requirements.Facilitates transfer of patients to other acute care facilities as required either due to third party payor requirements or county mandated indigent program.Maintains accurate records of all activities relating to the case management/utilization management process.Maintains working knowledge of regulations and provider contracts governing coverage of inpatient services, i.E., Medicare, Medi-Cal, California Children Services, Genetically and Handicapped People Program.Performs UR criteria screens all patients and formulates discharge plans within two working days of admission.Interviews patients and families to obtain relevant information and develops discharge plan with input from other members of the health care team.Provides information and makes referrals as appropriate to implement the plan such as community resources, home health care, institutional placements, financial assistance, equipment needs, and catastrophic case management by third party payors.Refers children in a vegetative state to regional center for placement as needed.Identifies situations needing psychosocial intervention and promptly refers them to Social Services.Maintains accurate and through documentation of discharge planning activities to include those mandated by third party payors.
Records information in the medical record in a timely manner.Works collaboratively with the nursing staff/other disciplines to support and achieve the goals of the collaborative care process.Handles all information obtained through the above process with utmost confidentiality.Works closely with other members of the health care team to facilitate the above process.Maintains objectivity and good interpersonal skills, which allow for effective interaction with a wide variety of people.Participates in staff meetings, committee meetings, team conference and other activities as assigned.Maintains accurate and updated review notes/records of payor UR activities as required.Identifies and refers situations requiring immediate intervention to Risk Management/QI Director or Medical Director as indicated.Participates in the orientation of new employees or cross training of other case managers as needed.Participates in mandatory UR/CM/DP staff education or hospital in-services.Participates in department quality improvement programs/projects/audits.Demonstrates an understanding of Valley Presbyterian Hospital’s vision, Mission and Guiding Principles, and incorporates them into daily performance.Proactively seeks team-building and positive working relationships with all hospital staff and physicians.Demonstrates a continuing effort to improve the quality of his/her performance to better the Organization.Performs other related duties as assigned.The following job accountabilities are not unique to this particular job but are common to all jobs at VPH:Complies with VPH policies and procedures on customer satisfaction and service excellence.
Demonstrates professionalism and cultural sensitivity in coordinating activities and communicating with all customers, peers, and the community at large.
Conducts self in a professional, respectful and courteous manner during all interactions.
Works effectively and collaboratively with others toward common goals.Communicates accurately, honestly, supportively and in a timely manner with department and interdepartmental team members.
Demonstrates effective business writing and oral communication skills, handwriting is clear and legible.Participates in operational aspects of the department, and maintains/participates in performance improvement activities within the department.Participates in all departmental specific training, Environment of Care (injury/illness prevention, fire/life safety, hazardous materials, emergency preparedness, utilities management, medical equipment management, safety and security management), infection control (standard precautions, TB Exposure Control Plan, Bloodborne Pathogen Exposure Control Plan).Demonstrates knowledge of and follows safety practices.
Understands the importance of safety, including patient safety in the work place.
Maintains a safe environment for self and others.Actively participates in the Patient Safety Program, including event reporting.
Identifies sentinel events/near misses and responds per defined organization processes.
Participates in education activities and process implementation.
Demonstrates advocacy for the patient/customer and appropriately acknowledges patients, customers and visitors.The above statements reflect the essential functions considered necessary to describe the principle content of the job.
They are not intended to be a complete statement of all work requirements or duties that may be inherent in the job.WORK ENVIRONMENT:Primarily an inside building/office environment, well lighted and ventilated, which may consist of multiple treatment and/or work sites.Fast and continuous work pace with variable workload.Frequent contact with staff and public under a variety of circumstances.Requires ability to communicate clearly (in English) verbally and in writing for effective communication with other staff members, physicians, vendors, community members, patients and patient families, employees and applicants of all socio-economic levels from a diverse cultural and ethnic population.Subject to many interruptions from multiple calls and inquiries and potentially emotional situations involving accidents, injuries, illness and/or death.Handles emergency/crisis situations in accordance with Hospital policy.Answers phones or pages; may carry a beeper/pager, and/or use a two-way radio.Occasional travel may be required.Potential risk of exposure to hazards from chemicals (toxic and non-toxic), flammable materials, gas or electrical or radiant energy or equipment with/without moving partsPHYSICAL DEMANDS: Patient Care ( Continuous: 66 to 100% of time, Frequent: 33 to 65% of time, Occasional: 0 to 32% of time)Continuous standing/walking and occasional/intermittent sitting.Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and shoulder level to handle/operate medical equipment/devices.Frequent reaching above shoulder level and overhead.Frequent forward bending, twisting, squatting and kneeling; occasional climbing.Occasional repositioning and transferring patients weighing up to 200 pounds between bed, chair, and gurney.Occasional lifting and carrying equipment weighing up to 25 pounds.Occasional/intermittent pushing of gurneys, wheelchairs, bed and other medical equipment over tiled and carpeted surfaces.Continuous use of near vision to read medical equipment such as monitoring devices and reading documents and computer screens; hearing and verbal communication to interact with patients, co-workers, and other customers.