PACE Transition of Care Nurse Case Manager

Transition Of Care Nurse Case Manager

Under the direct supervision of the PACE Transition of Care Manager, the Transition of Care Nurse Case Manager is responsible for all utilization management and care coordination activities on an ongoing basis. This position works closely with the PACE Transition of Care Manager in addition to the PACE Medical Director to evaluate and monitor medical appropriateness, determinations, and care coordination activities. This position is responsible for developing and implementing a plan which will have a direct impact on improved outcomes and cost containment.

Essential Functions of the Job:

• Performs prospective, initial, and retrospective reviews on all inpatient, facility, outpatient, and home health services assessing for appropriateness and medical necessity of the treatment requests using nationally recognized guidelines.
• Assess quality and clinical risk issues on a concurrent basis, reporting any recognized issues to the team and Medical Director.
• Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
• In conjunction with the Medical Director, evaluates and provides feedback as needed to treating physicians regarding participants discharge and homecare plans and available covered services including identifying alternative levels of care that may be covered.
• Presents facility-patient status updates and addresses barriers to discharge/transition at team meetings.
• Develops strong working relationships with outside contracted providers, case managers, and admissions department/personnel.
• Assesses documentation of medical records for completeness and relationship to the treatment plan and identifying gaps or barriers in treatment plans.
• Coordinates an interdisciplinary approach to support continuity of care.
• Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed by members.
• Facilitates on-going communication between staff and contracted providers to ensure authorizations are secured in a timely and efficient process. Coordinates care and services as needed (hospitalization, skilled care, home health, DME, etc.) including making referrals to outside sources.
• Coordinates identification and reporting of potential high dollar utilization cases. Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities and service providers.
• Works with QA to help prepare compliant notification letters of non-certified and negotiated days and services within the established timeframes.
• Reviews all NON-certification files for correct documentation.
• Assists in the identification and reporting of potential quality of care concerns.
• Responsible for assuring these issues are reported to the Quality Improvement Department.
• Participates in Transition of Care team meetings, reviews and discusses with providers evidence-based care options and proposes alternative levels of care.
• Investigate and follow up on complaints, grievances and quality issues related to patient acute or skilled level stays.
• Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and mitigating excessive health care expenditure.
• Reviewing data and how predictive analytics may be emphasized on helping to mitigate access to emergent facilities within 30 calendar days and or a value-based reimbursement model.
• Develop and monitor a standard practice in care based on those who may benefit from a palliative-hospice platform due to disease trajectory and prognosis. Assist patients in understanding their diagnosis, treatment options, and the resources available, including educating eligible patients about appropriate clinical research studies and technologies.
• Valid driver's license and reliable transportation for participants visit.

Additional Duties and Responsibilities:

• Works independently and as an effective member of the team. Multi-tasking for projects and their respective activities, timelines, and issues.
• Demonstrate ability to inter-relate with physicians, nurses, patients, internal departments, outside agencies, and the public.
• Demonstrate customer-focused service skills. Knowledge of PACE regulations related to eligibility requirements and plan specifics.
• Working knowledge of InterQual or other evidence-based care guidelines.
• Basic physical, psychosocial, and functional assessment skills.
• Able to collaborate between San Diego PACE and community resources.
• Thorough knowledge of appropriate utilization of acute hospital, long-term care, and homecare resources.
• Able to document concise yet thorough clinical documentation of patient assessment and care needs.
• Demonstrated strong communication and customer service skills, problem solving, critical thinking, time management, organizational skills, and clinical judgment abilities.
• Familiarity and ability to use computers as well as EHR's. Complies with all department, organization, and government policies & procedures.
• Attends meetings and trainings as required. Adheres to and models SYHC's core values and behaviors of Excellence, Empowerment, Integrity, and Respect.
• Adheres to SYHC and PACE attendance and punctuality policies and practices. Performs other duties as assigned.

Job Requirements:

Experience Required:

• 1 year of RN experience working in a hospital, PACE program and/or Utilization Management.

• Knowledge of PACE regulations (state and federal), principles and practices of health care service delivery, managed care, health care systems, and medical administration

• Experience performing audits analyzing productivity and quality of Utilization Management.

• Knowledge and/or experience with the senior care market, including competitors, regulations, and available resources

Education Required:

• Associate degree in nursing (ASN)

Education Preferred:

• Bachelor's degree in nursing (BSN)

Certification Required:

• Currently licensed in CA as a Registered Nurse license; must present credentials which demonstrate ability to meet performance criteria for RN.
• Maintain active BLS Certification

Equipment Used:

• EPIC EMR experience

Verbal and Written Skills Required to Perform the Job:

• Excellent oral, written, and interpersonal communication skills.

Technical Knowledge and Skills Required to Perform the Job:

• Must possess the skills to thrive in team environment, must possess good organizational and supervisory skills, and ability to effectively handle difficult and unusual interpersonal situations.
• Meet a standardized set of competencies for the specific position description established by San Diego PACE and approved by CMS.
• Microsoft Office experience

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.