LVN Case Manager Assistant - Fontana Medical Center - New - Utilization Management - Full Time

Job Summary

The LVN/LPN 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 Licensed Vocational /Practical Nurse LVN/LPN 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 individuals 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.
• Maintain and foster timely and accurate with all members if the multidisciplinary team.
• Escalates barriers to patient care as appropriate
• Other duties assigned.
• (30% daily, essential).
• Transition Management:
• Makes referrals for post-acute services based on needs identified by the RN Case Manager or SW staff assessment and utilizing the electronic Case Management system
• Provides patients and families with choices of post-acute providers per Kaiser policy.
• Based on SW and RN assessment and plan follows up on readmitted patients and implement strategies to address opportunities outlined.
• Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers.
• Identifies and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes documentation in the Case Management system to communicating information through clear, complete and concise documentation
• (30�ily, essential)
• Care Coordination:
• Follows up on patients identified by the SW and /or RN Case Manager on factors that may affect the progression of care
• Ensures consults, testing and procedures are sequenced to support the patients clinical needs with timely and efficient care delivery
• Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
• Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical and transition outcomes.
• (15% daily, essential).
• Education:
• Contributes to the education to patients and the care team relevant to the
• Effective progression of care,
• Appropriate level of care, and
• Safe and timely patient transition
• Provides patients and healthcare team information regarding resources and benefits available to the patient along with the economic impact of care options
• Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge
• (15% daily, essential).
• Compliance:
• Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
• Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Kaiser policies.
• Operates within the LVN/LPN scope of practice as defined by state licensing regulations
• Remains current with Kaiser Utilization Management/Case Management practices
• (10% daily, essential)
• PRIMARY INFORMATION, TOOLS AND SYSTEMS USED:
• Patient data - hospital admission, discharge, transfer system
• Healthcare staff documentation related to patient care
• Regulatory and payor requirements
• Kaiser Plan benefits
• Health Connect
• Tapestry
• McKesson Care Enhance Review Manager (CERMe) InterQual system
• Clinical data interface and secure faxing
• Patient Medical Record including Health Connect and Tapestry
• Hospital specific Clinical Software
• PERFORMANCE METRICS AND EVALUATION:
• The metrics below provide an indication of the effectivene