Job Information
Actalent RN Case Manager - GRAVEYARD SHIFT in San Diego, California
Description:
The RN Case Manager Assistant is responsible to conduct medical necessity screening and work collaboratively with the interdisciplinary team to provide care coordination for patients under the direction of a Registered Nurse and in compliance with evidence-based practice and regulatory requirements. This position complies with the scope of services defined by the Registered Nurse RN state licensure requirements.
This position integrates national standards for case management scope of services including: Utilization Management supporting medical necessity and denial prevention, Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care, Compliance with state and federal regulatory requirements, TJC accreditation standards and policy Education provided to physicians, patients, families and caregivers, and other duties assigned. Essential Responsibilities: The individual's responsibilities include the following activities:
a) accurate medical necessity screening and submission for Physician Advisor review
b) care coordination,
c) implementation of the transition plan based on RN Case Manager and/or Social Worker (SW) assessment(s),
d) communication with interdisciplinary team during patient care conferences,
e) management of concurrent disputes,
f ) communication with patients and families regarding the plan of care established by RN, SW and Physician,
g) collaboration with physicians, office staff and ancillary departments,
h) clear, complete and concise documentation in electronic system,
i) maintenance of accurate patient demographic and insurance information,
j) identification and documentation of potentially avoidable days,
k) identification and reporting of over and underutilization,
l) and other duties as assigned
Utilization Management: Assures the patient is in the appropriate status and level of care based on Medical Necessity process and submits for Secondary Physician review per Kaiser policy. Ensures timely communication of clinical data to various payers to support admission, level of care, length of stay and authorization for post-acute services. Advocates for the patient and hospital with payers to secure appropriate payment for services rendered. Completion of clinical reviews. Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes. Identifies and documents Avoidable Days using the data to address opportunities for improvement. Prevents denials and disputes by communicating with payers and documenting relevant information. Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) supported by evidence-based practice, internal and external requirements. Identifying appropriate level of care needs. Assisting with patient transition to the appropriate level of care. Order clarification admission status and patient classification.
Skills:
case management, acute care, registered nurse, utilization management, Care management, Health care, Medical, Insurance verification, Customer service, Rn license
Shift:
9PM - 7AM
Top Skills Details:
case management,acute care,registered nurse,utilization management
Additional Skills & Qualifications:
Registered Nurse - NEEDS ACUTE CARE EXPERIENCE
ED Experience & Epic Experience
Experience Level:
Intermediate Level
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
Diversity, Equity & Inclusion
At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:
Hiring diverse talent
Maintaining an inclusive environment through persistent self-reflection
Building a culture of care, engagement, and recognition with clear outcomes
Ensuring growth opportunities for our people
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.