What are the responsibilities and job description for the Case Manager - LVN position at Pioneers Memorial Healthcare District?
Job Description Job Description BRIEF SUMMARY : A licensed nurse responsible for conducting preadmission, admission, concurrent and retrospective utilization review AND discharge Planning Assessment.ESSENTIAL FUNCTIONS : 1. Reviews all in-house commercial and Managed Medical and Medicare patients as indicated by the Utilization Management Plan.2. Conducts concurrent and retrospective reviews to determine severity of illness and intensity of services using current guidelines and / or criteria (InterQual).3. Contact doctors regarding length of stay when cases fail intensity, severity or discharge screens and arrange peer to per contact as needed4. Responsible for follow-up with payors regarding certification of stay in hospital.5. Reviews Observation patients for program compliance.6. Responsible for reporting problem cases to Utilization Manager for follow-up.7. Tracks, trends and display utilization data (DRG, charges, costs, LOS and procedures and avoidable days). Documents and addresses service delays.8. Maintains statistics of case load through activity log.9. Commercial, Medicare and Medical Denials and Appeals.10. Perform RAC reviews when added information is requested by RAC.11. Review RAC denials and Appeals.12. Obtain prior authorization for post discharge services with insurances13. LVN who provides care to Joint Replacement patients will receive 1 hour of ortho / joint replacement specific education yearly .OTHER RESPONSIBLITIES : 1. Participates in quality improvement studies and projects at the department and facility level.2. Performs other job-related tasks as requested by the Manager of Utilization Review / Discharge Planning.3. Participates in monthly departmental and safety meetings.4. Proficient with computer as related to the affinity system and hospital network.5. Knowledgeable in State and Federal regulations and accreditation standards. Participates in the preparation and ongoing activities of the facility to meet regulatory requirements of JCAHO, DNV and Department of Health Services.SUPERVISORY RESPONSIBILITIES : NoneEDUCATION, KNOWLEDGE, SKILLS, ABILITIES AND EXPERIENCE : 1. Minimum of two years clinical experience. Experience in UR and / or CM preferred. Knowledge of financial and reimbursement issues.2. Computer skills.3. Strong interpersonal communication skills and leadership qualities.4. A collaborative approach and ability to influence clinical practice and gain cooperation with physicians and clinical staff.LICENSES AND CERTIFICATIONS : Current LVN license in the State of California is required.Current AHA BLS certification required.AGE OF POPULATION SERVED : Newborn Infant / Pediatric Adolescent Adult Geriatric All X No Patient Care
