RN/LVN Regulatory Case Manager


Under the direct supervision of the Leads & Clinical Supervisor for Case Management, the RN/LVN Case Manager is responsible for assessing, planning, implementing monitoring and evaluating options and services to develop o patient focused action plan for their patients. The RN/LVN Case Manager acts as patient advocate through the continuum and is available to the physician, patient and family as a resource to facilitate communication. As patient advocate, he/she also monitors patient care to ensure that the patient receives quality care through the use of standards of care and practice guidelines.

Duties and Responsibilities

  • Performs medical, functional, safety, nutritional and psychosocial assessments on targeted assigned caseloads to evaluate the member’s needs and coordinate appropriate care. Case management of the targeted cases should be problem focused and address risks.
  • Documents issues, problems, appropriate interventions and follow up evaluations to be entered in a care plan based on regulatory requirements.
  • Familiar with Case Management Policies and Procedures and its function. Must be able to manage diverse areas of understanding and interface effectively with all employees, members, employers, MPM personnel and providers.
  • Provides open, sensitive timely communication with patients, families, and their significant others to participate in the patient’s care. Identify support systems from family and community resources. Assist the CM Department for assuring continuity of care between units within the hospital or between the hospital and other facilities or the home, by mobilizing resources necessary to assure a prompt discharge as soon as the hospital level of care is no longer necessary.
  • Understands the managed care philosophy, including advanced knowledge of HMO policies and procedures and the managed care industry.
  • Schedules and participates in the Interdisciplinary Care Team (ICT) Meeting as they relate to his/her target cases.
    • At a minimum, prepare a summary of the target case with the following: brief clinical history and identified needs, medical history, pertinent primary care/ specialty care visit notes, medications, assessment, barriers, interventions, instructions, resources, outcome and plan.
    • Be prepared to communicate with the ICT members any active cases in order to obtain any additional direction needed to case manage the targeted cases.
  • Coordinates and completes special projects as delegated by the Care Coordination Leadership team.
  • Maintains effective communication with managed care plans, physicians, hospitals, extended care facilities, members, MPM contracting department, and co-workers concerning the referral process.
  • Collaborates with Social Work team to coordinate care and services for targeted case load.
  • Assists in the preparation of Health Plan audits in a timely fashion.
  • Performs or assume other duties as assigned. Must show initiative.
  • Assists with orientation and training for new employees as needed.
  • Ensures cases prepared for audits by the scheduled due date.
  • Documents according to CMS/MOC guidelines (i.e.; 3 outreach attempts on separate days)
  • Ensures ICP creation for HRA, PPG Data Transfer, Transitions of Care and Newly Eligible members are completed by required due date according to CMS/MOC guidelines
  • Refers members over to Health Plan Complex Case Management as needed
  • RN Case Manager reviews and verifies ICP completion by LVNs within 48 hours of receipt

Minimum Job Requirements

  • Current California RN/LVN License
  • 1-2 years Acute Care experience, 1-2 years’ experience in Basic/ Complex Case Management a plus
  • 1 year experience in Managed Care.
  • Working knowledge of the Standards of Practice for Case Management and the ability to implement the standards of practice in the day to day interaction with the members.
  • Adheres to HIPAA regulations and policies in relation to confidentiality of patient information that involves members, co-workers, etc.
  • Literate in Microsoft Office programs necessary for word processing or report generation.

Knowledge, Skills and Abilities Required:

  • Medical experience helpful, particularly as related to Medical Terminology, knowledge of ICD-9, CPT, and HCPCS coding.
  • Minimum one (1) or more years of experience as a referral authorization coordinator/ specialist in an IPA/ Medical Group or Health Plan setting.
  • Must be detail oriented and possess communication skills, both verbal and written.
  • Must be computer literate with basic office and computer skills.
  • Good interpersonal skills.
  • Bilingual, EZ-CAP and ESSETTE knowledge a plus.
  • Must be able to manage diverse areas of understanding and interface effectively with all employees, members, employers, MPM personnel and providers

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