Complex Case Manager (LVN or RN)
at RCM Health Care Services

Date Posted: 11/15/2019

Job Description

Local Health Plan with a highly professional office environment is seeking an Inpatient Case Manager (LVN or RN) for a mostly telephonic role in their corporate office in Chatsworth! Family feel environment, Mon-Fri hours, no nights/weekends!
 
Inpatient Case Manager (LVN or RN)
  • Responsible for the oversight of member’s inpatient utilization,
  • Identify high risk / high cost cases to be placed in Case Management
  • Manage these members through a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes.
  • Daily assessment of hospitalized patients for medically necessity of continued stay.
  • Review of each admission on daily census for appropriateness of admission based on diagnosis, correct hospital based on plan, correct Hospitalist assigned to the case, appropriate diagnosis codes, level of care, length of stay and member eligibility based on clinical criteria guidelines.
  • Obtain extensive concurrent review from hospital Case Manager, discussing plan of care and anticipated length of stay according to the Milliman Care Guidelines.
  • Enter into Medical Management system verbal reviews obtained and plan of care.
  • Reviewing written progress notes submitted by hospital Case Manager and entering into system.
  • Review all in-house complex cases with Medical Director and carry out special instructions. 
  • Notification to Full Risk Hospitals of any of their members out of network or at a tertiary facility requiring an extensive stay.
  • Transfers of members to tertiary facilities for higher level of care.
  • Out of Network members – Out of Network cases are reviewed with the hospital case manager. Aggressive review to move patients back in network immediately upon stability. 
  • Out of Network members requiring transfer – After the hospital is determined where the member will be transferred to, a doctor to doctor review must be arranged. If our hospitalist accepts the patient, a bed must be ordered at the receiving hospital.  Transportation is arranged and the hospital informed when the bed is available.  In the event a hospital does not have a bed ready during working hours, responsible to set  both facilities up with a hospital to hospital transfer when bed is ready. 
  • Coordinate discharge planning with hospital case management to assure quality continuum of care at discharge.  Review and approval of all DC orders.
  • Coordinates care of all out-of-area cases with providers and the health plan
  • Identifies cases of potential or confirmed quality or risk and provides case information to CM Nurse to set up Case Management for tracking, action, and follow-up.Qualifications:
  • CA LVN or RN (Registered Nurse)
  • Excellent communication skills when interacting with physicians, patients, and service providers
  • Must have been a previous Inpatient Case Manager in Hospital or Managed Care (health plan, IPA, etc) setting  Compensation:
  • Competitive Salary plus bonus, flexible based on experience
  • Full benefits package

Job Snapshot

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