Case Manager Continuing Care Coord RN - San Diego, Per Diem - Days

• Plans, develops, assesses and evaluates care provided to members.


• In conjunction with primary care and specialist physicians, evaluates and develops baseline medical and psychosocial evaluations and individualized patient care/treatment plans.


• Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.


• Develops individualized patient/family education plan focused on self-management; delivers patient/family education specific to a disease state.


• Encourages member to follow prescribed course of care (e.g., drug therapy, physical therapy).


• Coordinates care/services with utilization and/or quality reviewers and monitors level and quality of care.


• Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining all authorizations/approvals/transfers as needed for outside services for patients/families.


• Makes referrals to appropriate community services and outside providers.


• Coordinates transmission of clinical and benefit treatment to patients, families and outside agencies.


• Consults with internal and external physicians, health care providers, discharge planning and outside agencies regarding continued care/treatment, hospitalization or referral to support services or placement.


• Arranges and monitors follow-up appointments.


• Coordinates repatriation of patients and monitors their quality of care.


• Develops and collects data; trends utilization of health care resources.


• Produces population based reports on outcomes specific to defined patient populations.


• Participates with healthcare team/providers in actualizing outcomes by planning, evaluating and implementing decisions and strategies to achieve predetermined cost, clinical, quality, utilization and service outcomes.


• Develops and maintains case management policies and procedures.


• Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.


• Interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.


• Acts as liaison for outside agencies, non-plan facilities, and outside providers.


• Participates in committees, teams or other work projects/duties as assigned.

Basic Qualifications:

Experience

·       Minimum one (1) year clinical experience as an RN in an acute care setting, plus two (2) years clinical experience as an RN in a licensed home health or hospice agency required. 

·       For positions in Special Needs & Care Programs (Care Plus/Guidance):  Two (2) years clinical experience as an RN in an acute care setting required.

Education

·       Please refer to Minimum Work Experience and Qualifications Sections.

License, Certification, Registration

·       Registered Nurse License (California)

·       Basic Life Support

Additional Requirements:

·       Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques and methods of utilization review/management, discharge planning or case management.

·       Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc.).

·       Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking and problem-solving skills required.

·       Computer literacy skills required.

Preferred Qualifications:

·       Case Management Certification preferred.

·       Bachelor's degree in nursing or healthcare related field preferred.

·       Palliative Care and Hospice experience preferred.