Remote Inpatient Nurse Case Manager (LPN/LVN, RN) – California

Position Summary / Responsibilities:

· Comply with Care Management policies and procedures.

· Effectively manage patients telephonically during their hospitalization to ensure the appropriate level of care is provided for the patient’s severity of illness. Utilizes the appropriate tests and diagnostics in the right facilities to facilitate the highest level of care in the most efficient manner. Communicates effectively with facility staff and hospitalist to gather clinical information through verbal and written communications. Provides timely and accurate responses to request information or provide authorization decisions.

· Develops a working relationship with the hospital case managers, health plan, clinics, hospitalists and other governing entities.

· Interacts with hospitalists and patients daily to evaluate plan of care including discharge planning to determine that patients are receiving quality care and appropriate discharge disposition. Applies medical knowledge to authorize outpatient services as an alternative to hospitalization when appropriate. Arranges for transfer to in-network care when appropriate.

· Updates clinical information in the electronic medical management record system with treatment plan, objectives, results and next steps. Documents all information accurately.

· Anticipates and initiates discharge planning within a timely manner of admission, completes post discharge call within a reasonable time frame to identify barriers and prevent readmission. Identifies post discharge care needs and refer to the appropriate outpatient programs and/or providers.

· Utilizes current approved criteria along with clinical experience to make authorization decisions. Identifies cases not meeting criteria and provides clinical information and rationale to the Medical Director for review and determination.

· Actively participates in daily rounds with current and accurate clinical information. Prepared to discuss current treatment plans from the Hospitalists or Specialists, plan of care for discharge disposition and continuity of care.

· May be required to take After Hours On-Call coverage as assigned.

· Refers cases to the Care Management Director as appropriate for denial of stay or review of potential observation status.

· May be responsible for timely development of denial letter language and member/provider notification regarding Medical Director’s review determination.

· Identifies and refers cases appropriately for CCS, High Risk, Homebound, Hospice/Palliative, SNF, QI and Health Education, per policy, and documents referral in case file. Actively participates in internal quality and workflow enhancement projects, and other duties, as assigned. Identifies and reports departmental operational issues and resource needs to the appropriate identifies and reports under and over utilization of medical services, delays in service by provider or hospital or treatment and quality of care issues to the Care Management Director.

· Other duties as needed.

Education and Experience

· Valid California Licensed Vocation Nurse (LVN) or Registered Nurse (RN) license.

· Five years+ clinical experience.

· Prefer of two (2) years+ experience in an HMO/IPA/Managed care setting is preferred and recommended.

· Ability to work independently with minimal supervision, exercising judgment and initiative.

· Ability to manage multiple tasks with effective prioritization.

· Process oriented.

· Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe

· Detail oriented and highly organized

· Strong ability to multi-task, project management, and work in a fast-paced environment

· Strong ability in problem-solving

· Ability to self-manage, strong time management skills

· Ability to work in an extremely confidential environment

· Strong written and verbal communication skills

Job Type: Full-time

Pay: $70,000.00 – $120,000.00 per year

Benefits:

• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid sick time
• Paid time off

Schedule:

• 8 hour shift
• Monday to Friday

Work Location: Remote