SUMMARY: The AHD Case Manager (RN) is responsible for providing comprehensive case management services to clients identified with complex health conditions and social challenges that are at risk for health status decline. The goals and focus of these service efforts are to provide timely delivery of intensive case management services during the transitional period beginning with hospitalization and culminating with integration back into the community setting to prevent further health deterioration and reduce the need for more costly services such as acute care hospitalization and to develop self-management skills that improve his or her long-term health status. Performs related duties as required. 

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level.  Not all duties listed are necessarily performed by each individual in the classification.

1.  Understands insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.  Takes appropriate action when cases do not meet criteria - coordinates denials with the attending physician, and the UR physician advisor.  Prepares case reports; documents treatment plan, progress notes and discharge summary related information as required by Medicare, MediCal, Title 22 and other mandated regulations according to Department standards. Keeps required statistics.

2.  Reviews all the patients in his/her caseload in the following areas; admission criteria for medical necessity and appropriateness of care; continued stay criteria for medical necessity and appropriateness of care; resource Management issues; other issues including concerns involving under/over utilization, avoidable days and quality issues.  Coordinate daily with interdisciplinary team in transitioning patient throughout hospital stay; provides discharge planning services, working with patient/family and receiving multi disciplinary input, so that an appropriate plan is developed enabling a patient to go home, or facilitates the relocation of the patients to another setting.

3.  Coordinates disposition of Medi-Cal, self-pay, and out-of-plan patients, including working with physician to determine readiness for transfer, securing placement and completing TAR and other documentation; contacts with payers conducting phone reviews and initiates denial appeals as needed.

4.  Conducts discharge planning assessments in a timely and complete manner.  Assessments and interventions; considers the age and cultural or religious influences of the patient/family.

5.  Guides the patient in understanding the nature of his illness; confers with patients and their families to prepare for the patients' discharge

6.  Provides community resource education and coaching, focusing on individual client self-management principles. This includes preparing for provider visits and supporting the disease management principles introduced by the nursing team.

7.  Reassesses the client's condition when changes occur and revises the care plan as appropriate. Coordinates and arranges for needed services with appropriate local resources. Serves as client advocate to secure services and financial benefits.

8.  Encourages patients to develop realistic plans.  Makes direct contact with or refers patient/family to appropriate community resources.  Maintains knowledge of currently available resources in the community.

9.  Serves as a mentor and educator to the organization's health care team assisting with care coordination, training, and quality improvement activities; provides staff education regarding Advance Directives and POLST when requested.

MINIMUM QUALIFICATIONS:

Education: Bachelor's degree in a related field. Master's Degree preferred. 

Minimum Experience: One year related in acute care facility and/or utilization review training and/or healthcare experience. 

Minimum Experience: Varied clinical experience or experience in case management/community health preferred. 

Required Licenses/Certifications: Valid license to practice as a Registered Nurse in the State of California. 

Required Licenses/Certifications: BLS - Basic Life Support Certification - issued by AHA-American Heart Association. 

Preferred Licenses/Certification: Public Health Nurse, Case Management, or Home Health.