Utilization Management Case Manager - Goleta, CA, United States

Description · Responsible for the utilization management, quality assurance, and discharge planning activities for assigned services/areas/patients within Cottage Health. Case management activities will result in quality outcomes, optimal care/cost management of services and/or p ...

Job description

Description
Responsible for the utilization management, quality assurance, and discharge planning activities for assigned services/areas/patients within Cottage Health. Case management activities will result in quality outcomes, optimal care/cost management of services and/or procedures, a high level of customer satisfaction and contribution to an overall value-oriented experience of stakeholders and persons served.

Responsibilities
This is not an exhaustive statement of duties, responsibilities, or requirements. Employees will be required to perform any job, with related instruction given by their supervisor, subject to reasonable accommodation.

• Resource Management: Understand the principles of reimbursement and the services within the reimbursement parameters. Ascertain healthcare benefits utilizing both internal and external resources as appropriate to coordinate necessary and appropriate care, while appropriately preserving the healthcare benefits of the beneficiary. Identify and refer situations requiring immediate intervention to the attending physician, risk management, department director and/or physician advisor as appropriate. Refer cases not meeting criteria (including situations involving the timely provision of services) to the department director and/or physician advisor as appropriate. Maintain accurate and thorough documentation of resource management activities to include those mandated by third party payers and CottageOne medical record. (20%)
• Discharge Planning: On admission, initiative the coordination and development of a discharge plan. In conjunction with the healthcare team, patient, and family stakeholders identifies likely post-discharge needs. Provide appropriate information, education, and choice, making referrals as appropriate to implement the discharge plan (such as community resources, home healthcare, institutional placements, financial assistance, equipment needs, and/or alternative/specialized care settings). Facilitate the transfer of patients to other care facilities as appropriate. Maintain accurate and thorough documentation of discharge planning activities to include those mandated by third party payers and CottageOne medical record. (50%)
• Quality Assurance: Participate in the improvement of organizational performance through quality assurance and performance improvement activities. Participate in the tolls, measurement, and continuous improvement of quality, productivity, value, and efficacy of case management functions. Support system-wide development, analysis, and implementation of process improvement initiatives. Report suspected and/or emerging patterns and trends. Participate in the denial/appeal process as appropriate, and cooperate fully in all risk management activities and investigations. (10%)
• Education: As appropriate, educate the patient/family to the care delivery process: provision of services, healthcare providers and resources, issues related to funding, and areas of patient choice and accountability. Explain the plan of care and treatments within the context of the patient's/family's values, and in a language understood by the patient/family. As appropriate, assist in coordinating an educational plan with the interdisciplinary healthcare team. (10%)
• Leadership and Collaboration: Provide consultation, support, and on-going education as needed to help promote and manage a value-oriented experience for persons served. Serve as a consultant for case management issues and as coach/mentor to others. Participate in care planning activities, rounds, committee meetings and other activities as appropriate. Demonstrate a continuing effort to improve the quality of his/her performance to better the organization (such as continuing education/professional development and/or through participation/membership with appropriate professional organizations).For example, "Reduce costs and improve user efficiency by designing automated solutions to data handling projects using analytical and programming skills." (10%)

Qualifications

All job qualifications listed indicate the minimum level necessary to perform this job proficiently.

LEVEL OF EDUCATION
Preferred:

• Associate's Degree in Nursing (ADN)
• Bachelor's Degree in Nursing (BSN)

CERTIFICATIONS, LICENSES, REGISTRATIONS
Preferred:

• Current California Nursing license in good standing (required as of June 2006)

YEARS OF RELATED WORK EXPERIENCE 
Minimum:

• 2 years direct patient care experience in an acute care setting. Other patient care experience may be considered

Preferred:

• Previous experience as a case manager in an acute care setting.

KNOWLEDGE, SKILLS, and ABILITIES
All knowledge, skills, and abilities listed indicate the minimum level deemed necessary to perform this job proficiently.

• Excellent organizational and analytical skills required. Able to make independent decisions and utilize effective problem solving models and methods. Able to understand and leverage all continuum of care options
• Develops, maintains, and models professional, objective, and value-oriented interpersonal skills, continuously promoting and fostering productive relationships. Maintain at all times positive and proactive communication with peers, supervisors, and other stakeholders to the department. Proactively seeks and fosters team-building relationships.
• The employee communicates effectively. Continuously demonstrates clear, objective, and professional communication at all times. Actively pursues and ensures both appropriate oral and written communication regarding case management functions, activities, and responsibilities.
• Working knowledge of regulations and provider contracts governing coverage of inpatient services (i.e. Medicare, Medi-Cal, California Children Services, Genetically Handicapped People Program, Contracted Medical Groups). Able to demonstrate an understanding of InterQual criteria. Able to assess discharge planning needs of a diverse population.