Complex Case Management, RN

Status: Open Department: Utilization Management Purpose: Conducts telephonic or facility based case management in a collaborative process of assessment, planning, facilitation and advocacy for options and services.
Responsibilities: Builds effective relationships with members and other internal and external partners by using excellent verbal and written communication skills, developing trust, meeting timelines, respecting cultural differences, using active listening skills, and maintaining confidentiality.On Site Case Management: Conducts onsite and telephonic case review at the group, hospital or SNF within 24 hours of admission. Uses Severity of Illness (SI) and Interqual Intensity of Service (IS) criteria to evaluate necessity of services. Coordinates treatment plan, discharge expectations, discusses Advance Directive status with attending physician and family as appropriate. Coordinates necessary services with contract providers.
Telephonic Case Management: Selects appropriate cases to open by screening from internal or external referral sources and applying criteria for opening cases consistently.Manages cases by using essential activities of case management including assessment, planning implementation, coordination, monitoring and evaluation.
Participates in meeting the Care Transitions goals of empowering the member/caregiver to advocate for themselves; resulting in adverting hospital re-admissions within 30 days of discharge by consistently applying the Care Transitions Program content.Records timely written documentation showing evidence of all CCM and Care Transitions activities and provides status of case for internal case management team.Facilitates quality of care and service by referring any potential quality issue to the SCAN Medical Director and Quality Management Department.Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.Contributes to team effort by accomplishing related results as needed.

Job Requirements




Registered Nurse (Current and active California RN license in good standing) with Bachelors Degree in Nursing (BSN)

Case Management Certification or equivalent experienceExperience in a managed care environment
Minimum three years experience in medical-surgical nursingThree years utilization/claims review experience in the managed care industry
Proficient computer skills-typing test may be required
Education:
Current California Registered Nursing license.
SCAN is an Equal Opportunity Employer