Overview Responsible for the oversight and management of skilled patients and temporary skilled patients in rehabilitation in contracted Skilled Nursing facilities; this includes checking benefits, managing up to discharge and issuing denial letters. Works with primary care, specialist physicians and the healthcare team to coordinate a chronic disease care management program for patients. Coordinates with the assigned physician to manage Skilled nursing patients and directs families, patients, physicians, nurse practitioners and SNF staff to the appropriate level of care and identifies patients who do not meet criteria for Continued Skilled stay. Responsible for managing Custodial patients who require long term care for chronic disease management in SNFs. Must be able to work collaboratively with the Multidisciplinary team.
Essential Responsibilities
In conjunction with physicians and healthcare team, develops an individual care plan based on patient assessment/evaluation and diagnostic tests.
Monitors/evaluates patient progress and modifies treatment plan as appropriate in collaboration with the Multidisciplinary team.
Recommends additional levels of care, therapy/rehabilitation when medically indicated as appropriate.
Monitors levels and appropriateness of therapeutic and/or rehabilitative care.
Implements strategies to assure that patients and caregivers comply with and understand the importance of follow through on plan of care in collaboration with the Multidisciplinary team.
Provides individualized patient/family education focusing on teaching self-management.
Conducts individual and team conferences to help patients and families identify risk factors.
Facilitates patients’ return to normal daily activities by teaching and making appropriate referrals for outside services/continued care collaboratively.
Develops treatment program procedures, clinical guidelines/protocols and program evaluation/outcomes measures in collaboration with physicians and healthcare team.
Educates Inpatient Case managers about the appropriateness of transfers to the Skilled Nursing facility and transfer protocols.
Ensures patient has a safe and appropriate discharge and orders DME as ordered by the physician.
Screens by using senior metrics for Skilled patient expected Length of Stay.
Educates Inpatient Case managers/designees about admissions to the Skilled Nursing facility and admission protocols.
Intervenes when there are quality issues surrounding transfers and notifies members about co-payments associated with Skilled Nursing transfer.
Communicates with physicians and other care givers regarding patient progress by monitoring, evaluating and analyzing clinical, functional and psycho-social status/progress.
Issues reports and participates in inter-disciplinary case conferences and consultations.
Consults with the physician regarding senior metrics for appropriate length of stay for the Skilled population.
Contributes to medical and nursing staff education by delivering periodic in-service presentations.
Participates in inpatient UM staff meetings and in the review/evaluation of the quality, appropriateness and outcomes of diagnostic and therapeutic services and treatment programs.
Participates in committees, teams or other work projects/duties as assigned.
Experience
Minimum two (2) years clinical experience as an RN in an acute care setting required.
ECC Antelope Valley: One (1) year of Utilization Management experience, to include Discharge Planning.
Education
Please refer to Minimum Work Experience and Qualifications Sections.
License, Certification, Registration
Registered Nurse License (California)
Driver's License (California)
Basic Life Support (BLS)
Additional Requirements
Demonstrated ability to utilize/apply the general and specialized principles of utilization review/management, discharge planning and case management.
Working knowledge of regulatory requirements and accreditation standards (TJC, Medicare, Medi-Cal, etc.).
Strong written and verbal communication, interpersonal, critical thinking and problem-solving skills.
Computer literacy skills required.
Preferred Qualifications
Case Management Certification preferred.
Clear driving record for the past two (2) years.
Proof of automobile insurance as required by law.
Bachelors degree in nursing or healthcare related field preferred or current equivalent related work experience.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Hospitals and Health Care
Note: This description reflects the role responsibilities and qualifications as provided. Some sections may be repetitive due to the original formatting; content has been consolidated to present a clear, job-focused outline.