Applicants will only be eligible to proceed with the hiring process if the applicant: (1) is fully vaccinated and can provide proof of vaccination; or (2) qualifies for a medical or religious exemption that can be accommodated by Eisenhower Health.

group
Category
Management & Supervision
business
Department
Case Management Social Services
date_range
Schedule
Part Time
schedule
Shift
Varies
timer
Hours
8 Hour Shift
place
Location
Rancho Mirage, CA 92270
info
Job #
R0259151
  • Job Objective: A brief overview of the position.
    • The position is responsible for evaluating the medical necessity for admission and appropriateness of patient care unit placement for all scheduled admissions, direct admits, transfers, and outpatient conversions and provides consultation to physicians prior to patient placement.
  • Reports to
    • Manager, Case Management
  • Supervises
    • N/A
  • Ages of Patients
    • Neonate/ Infant
    • Pediatric
    • Adolescent
    • Adult
    • Geriatric
  • Blood Borne Pathogens
    • Minimal/No Potential
  • Qualifications
    • Education
      • Required: BSN or MSN if hired after July 1, 2012
    • Licensure/Certification
      • Required: California Registered Nurse
      • Preferred: Certification in Case Management
    • Experience
      • Required: Minimum three years recent acute care hospital Case Management
  • Essential Responsibilities
    • Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
    • Carries the Admissions Case Manager/Direct Admit Program cell phone and reviews all requests for admission and transfers for the hospital.
    • Acts as a resource to physicians and others regarding appropriateness of admission, levels of care (including related documentation requirements and observation vs. inpatient requirements), quality of care concerns and criteria/guidelines/protocols utilized in care planning and resource utilization.
    • Concurrently reviews all elective procedural and surgical cases against CMS criteria for outpatient, observation and inpatient status.
    • Ensures that the physician order matches the appropriate admission status and level of care.
    • Triages calls from other acute care facilities requesting patient transfers to EMC; determines transfer appropriateness by reviewing requested documentation and Interqual level of care criteria and discussions as necessary with admitting physician, supervisors and/or EMC administrators and/or other EMC personnel.
    • Recommends referral of cases to Physician Advisor or EHR when admission status is questionable.
    • Communicates with Nursing Supervisors regarding bed availability, bed placement and status of potential incoming transfers.
    • Communicates with the Financial Counselors when a patient does not meet criteria for admission so that appropriate consultation can be made and information on payment provided.
    • Gathers sufficient and relevant information from all sources in compliance with regulating requirements and laws, to facilitate appropriate admission to EMC in an accurate, safe, timely, and cost effective manner.
    • Gathers sufficient information from and communicates with all relevant sources to facilitate appropriate discharge from ED to appropriate level of care to assure it is done in an accurate, safe, timely and cost effective manner to prevent readmission and/or frequent visits to ED.
    • Performs pre-admission review of patients admitted from ED; performs inpatient admission review within 24 hours or first working day after admission and concurrent utilization review as necessary to assure payment authorization.
    • Assists in maintaining inter-facility transfer documentation logs, SBAR reports and other data as required. Ensures follow up of outstanding issues at end of shift.
    • Coordinates any unexpected discharge planning needs for this patient population that are not transitioned to the inpatient case managers, so that a smooth transition from the acute outpatient care setting to the community setting is ensured and readmission is averted.
    • Coordinates patient transfer to the appropriate level of care. Identifies and facilitates resolution of clinical and operational roadblocks to achieve optimal outcomes by identifying alternatives as needed. Communicates resulting decisions to patient/family, physicians and members of healthcare team.
    • Facilitates communication regarding the evidenced based plan of care, promotes collaboration among all members of the healthcare team and facilitates weekly multidisciplinary team care conferences.
    • Identifies opportunities to improve care/service. Assists in development and implementation of care performance improvement plans based upon analysis of patterns and trends identified from data collection and observations.
    • Organizes, integrates and evaluates the effectiveness of the plan of care and progress toward achievement of desired outcomes. Modifies plan of care as patient/family needs change to accomplish goals established in the plan of care. Communicates and documents plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team.
    • Demonstrates understanding of payer prior approval requirements and the various health care delivery systems and payer plan contracts. Communicates with third party payers and/or review organization as necessary and Provide information to federal, state, and privates payers and/or review organizations so that determinations regarding benefits and coverage may be made.
    • Complies with regulations, standards and legislation (local, state and federal) related to the continuum of care and patient transition
    • Issues notices of non-coverage/denial letters to patients based on results of physician reviews and in compliance with Medicare/CMRI, federal and state and department guidelines.
    • Identifies potential opportunities for cost savings and evaluates services provided, timeliness and costs; assists in action plan development and implementation as requested/appropriate.
    • Refers to Social Work those patients with complex psychosocial or discharge planning needs and follows-up to ensure appropriate intervention.
    • Performs other duties as assigned.