Registered Nurse,Care Manager

Join Our Team!Due to our tremendous growth, we are currently hiring at various locations. We have 32 medical sites located throughout the Greater Los Angeles, Pasadena/San Gabriel Valley, South Bay, Long Beach, and San Fernando Valley area.Responsible for ensuring the continuity of patient care in both the inpatient and outpatient settings utilizing the appropriate resources within the parameters of established contracts and patients' help plan benefits. Facilitates continuum of patients' care utilizing advanced nursing knowledge, experience and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs care management functions on-site or telephonically as the need arises. Performs other care management duties as assigned. Reports findings to the Care Management Department Supervisor/ Manager/ Director in a timely manner.
REQUIREMENTS
Implements and monitors current medical group Care Management programs within the policies and procedures set by the Care Management Department.
Conducts prospective, concurrent, and retrospective review of active patient care on-site or telephonic, including out of area and transplant, where assigned.
Reviews patients' clinical records of acute inpatient within 24 hours of notification.Reviews patients' clinical records within 48 hours of SNF admission.Reviews patient referrals within the specified CM policy time frame. ( Request Types and Timeline Policy)
Coordinates treatment plans, discharge expectations, and when applicable, discusses DPA and DNR status with attending physician.Prioritize patient care needs. Meets with patient, patient's family, and caregivers as warranted to discuss care and treatment plan.
Identifies and assists with the follow up of high-risk patients in acute care setting, skilled nursing facilities, custodial and ambulatory settings, consulting with the physician and other team members to ensure that the care plan is successfully implemented.Coordinates provisions for discharge from facilities, including follow up appointments, home health, social services, transportation, etc., in order to maintain continuity of care.
Communicates authorization/denial for services to appropriate parties. Communication may include patient (or agent), attending/referring physician, facility administration, and HCP claims as necessary.
Participates actively in assigned Care Management Committee meetings. Documents pertinent patient information, all communication, and Care Management Committee (CMC) decisions to all members of the health team when appropriate.Demonstrates a thorough understanding of the cost consequences resulting from Care Management decisions through utilization of appropriate reports: Health Plan Eligibility and benefits, (DOR) Division of Responsibility, and Bed Days, etc.
Ensures appropriate utilization of medical facilities and services within the parameters of the patient's benefits and/or Care Management Committee decisions. This includes appropriate and timely movement of the patient through the various levels of care.
Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients, and families.
Provides accurate information to patients and families regarding HMO benefits, community resources, referrals, and other related issues.
Maintains confidentiality of patient information at all times.
Initiates and/or oversees data entry into IS systems on all patients within parameters of Care Management policies and procedures. Maintains accurate and completes documentation of care rendered including LOC, CPT code, ICD 9, referral type, date, and etc.
Demonstrates flexibility when performing assignments in order to meet Department and Regional goals.
Follows patients on Ambulatory Care Management programs, including CHF and Home Health, in order to optimize clinical outcomes.Assumes other Care Management duties as delegated.