RN/LVN Case Manager
Under the direct supervision of the Manager, Case Management, the RN/LVN Case Manager is responsible to assess, plan, implement, monitor, and evaluate options and services to develop a patient focused action plan for patients. He/she collaborates with the primary physician and other health care team members in the development of the patient goals and action, ensuring the formulation of a realistic and definitive goal that represents the total care needs and resources of the patient and family. He/she facilitates the patient’s progression through the care continuum and effects appropriate changes in collaboration with the health care team, the patient, and community resources assessing for critical factors necessary to determine the patient health, functional status, and psychosocial well- being, while maintaining patient satisfaction and management of cost effective quality interventions.
The RN/LVN Case Manager identifies and monitors patients with complex disease states and provides patient/ family education and direction within the scope of nursing practice. Working with the PCP or specialist, the RN/LVN Case Manager (with the patient’s consent) assists in the coordination of medical services and with transitions between levels of care and makes appropriate referrals for community services for the patient and family/ caregivers. He/she participates in data collection and analysis to support care management outcomes and identify performance improvement opportunities.
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
- Respects the dignity, confidentiality and privacy of each patient and adheres to HIPAA regulations and policies in relation to confidentiality of patient information that involves members, co-workers, etc.
- Perform 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.
- Documentation will be kept in a care plan which define the issues, problems and appropriate interventions and include follow-up evaluations. Evaluations of the treatment plan are to occur on a quarterly basis; however, the cases are to be concurrently monitored; i.e. in-patient hospitalizations, re-admissions, multiple ER utilizations, etc. Documentation will include but not be limited to:
- Initial assessments of member’s health status, including condition-specific issues;
- Documentation of clinical history, including medications;
- Initial assessment of activities of daily living (ADLs);
- Initial assessment of behavioral health status, including cognitive functioning;
- Initial assessment of life-planning activities;
- Evaluation of cultural and linguistic needs, preferences or limitations;
- Evaluation of caregiver resources
- Evaluation of available benefits
- Development of case management plan with short and long term goals;
- Identification of barriers to meeting goals or complying with the plan
- Development of a schedule for follow-up and communication;
- Development and communication of self-management plans
- Process to assess progress in case management plans.
- Initiate referral to Health Plan’s Disease Management as needed.
- Initiate referral to Managed Long Term Services and Supports (LTSS), i.e., IHSS, CBAS, MSSP, LTC, etc.
- Must be familiar with Case Management Policies and Procedures and its function. Provides open, sensitive timely communication with patients, families, and their significant others to participate in the patient’s care.
- Must understand the managed care philosophy, including advanced knowledge of HMO policies and procedures and the managed care industry.
- Must be able to manage diverse areas of understanding and interface effectively with all employees, members, employers, MPM personnel and providers.
- Maintains confidentiality when working with medical information that involves members, co-workers, etc.
- Must be detail oriented and possess strong communication skills, both verbal and written to document, assess and communicate with other staff members the plan of care which requires coordination.
- Must be computer literate in Microsoft Office programs necessary for word processing or report generation.
- Recommend enhancements and/or changes that would improve the existing case management program.
- Familiarity with medical guidelines such as McKesson InterQual, Milliman Care Guidelines, Apollo Medical Review Criteria, Health Plan established guidelines; utilized for daily case management duties.
- Gather and organize monthly, quarterly and annual CM reporting logs within established timeframe and forward to Manager of Case Management.
- Participate 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.
- Coordinate and complete special projects as delegated by the Manager of Case Management.
- Participate in tracking, analyzing and reporting of information on cases assigned for the specific PPG/IPA.
- Communicate contracting needs and opportunities to the manager, monitor follow-up.
- Participate in Committees and in projects related to the overall well- being of MPM as requested.
- 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.
- Maintain effective communication with managed care plans, physicians, hospitals, extended care facilities, members, MPM contracting department, and co-workers concerning the referral process.
- Provide accurate information to members regarding benefits, community resources, referrals and other related issues. Make sure that staff follows same guidelines.
- Assist in coordinating services for high cost/ high utilization cases as the resource manager so members obtain appropriate outpatient services to minimize inpatient utilization.
- Utilize social work experience to coordinate care and services for targeted case load.
- Daily work to include compliance with State, Federal, and Health Plan mandated
- Assists in the preparation of Health Plan audits in a timely fashion.
- Perform or assume other duties as assigned.
- Assist with orientation and training for new employees as needed.
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. 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. High school graduate or GED. Good interpersonal skills. Bilingual, EZ-CAP and ESSETTE knowledge a plus.