Case Manager, RN, SR - Pre Access

Job Summary

The Case Manager RN SR - Pre Access is responsible for ensuring that ED CM utilize standards of practice for Case Management in addition to screening, coordinating, and facilitating admission review of all acute patients. Working collaboratively with all interdisciplinary staff,  facilitates admission and transfer of patients, ensures that each patient is admitted meeting established medical guidelines in collaboration with credentialed medical staff, assists with the coordination of patient transfers into the hospital, and communicates all requested and questionable admissions/transfers to the Director of Case Management,  and/or Physician Advisor.  The Case Manager RN SR follows all guidelines related to the clinical ladder for requirements in obtaining and renewing senior status. The Case Manager RN SR will have oversight over monitoring the denials process, and take responsibility for mentoring the staff as needed.

Licensure and Certification:

• Current CA RN license
• Current BLS provider card
• Case Management certification preferred

Education:

• Diploma, AA, BS in Nursing
• MS in Nursing preferred

Experience:

• Two years as a Case Manager in an acute care setting or five years recent acute care nursing experience preferred
• Experience in Critical Care setting preferred
• Demonstrates strong interpersonal skills, leadership ability, negotiation skills, and knowledge of hospital operations. General knowledge of the payer industry, resource management, reimbursement, and evidence-based clinical practice is essential
• Advanced experience utilizing InterQual required

Knowledge and Skills:

• Develops, maintains, and models professional, objective and value-oriented interpersonal skills. Continuously promotes a patient-centered philosophy
• Maintains positive and proactive communication with patients, families, staff members, and physicians
• Fosters team-building relationships
• Excellent organizational skills and the ability to problem solve are essential
• Strong interpersonal skills, leadership, negotiation skills, good leadership talent
• Knowledge of the payer industry, resource management, reimbursement, and evidence-based clinical practice is essential
• Knowledge of State and Federal regulations; e.g. EMTALA, Medi-Cal, HMOs, etc.
• Understanding of Medicare, Medi-Cal and other Third Party Payer regulations
• Understanding of current utilization/quality management principles, techniques and procedures
• Knowledge of current utilization/quality management principles, techniques and procedures

Physical Demands - Patient Care:

• 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.