The RN Case Manager-Pre Access will be responsible to screen, coordinate, and facilitate admission review of all acute patients per medical necessity guidelines. In addition, the RN Case Manager-Pre Access will work collaboratively with all interdisciplinary staff, internal and external to the organization for facilitating admission and transfer of patients as necessary, ensure that each patient is admitted meeting established medical necessity guidelines in collaboration with VPH credentialed m... more details
JOB SUMMARY:
The RN Case Manager-Pre Access will be responsible to screen, coordinate, and facilitate admission review of all acute patients per medical necessity guidelines. In addition, the RN Case Manager-Pre Access will work collaboratively with all interdisciplinary staff, internal and external to the organization for facilitating admission and transfer of patients as necessary, ensure that each patient is admitted meeting established medical necessity guidelines in collaboration with VPH credentialed medical staff, assist with the coordination of patient transfers into the hospital, and communicate to the Director of Case Management, VPH Physician Advisor, internal or external, all questionable admissions/transfers requested as necessary. This position will also have an overall responsibility for VPH admission reviews are conducted onsite 24 hours/day, Sunday through Saturday.
EXPERIENCE/QUALIFICATIONS:
Minimum of two (2) years direct patient care experience in an acute setting. Critical Care experience desirable. Previous experience in Case Management, Utilization Management or Discharge Planning preferred. Must be able to assess discharge-planning needs of a diverse cultural and ethnic population.
Must be able to demonstrate the knowledge and skills necessary to provide appropriate case management specific to the age of the patients served on assigned units. Case Managers are assigned patients ranging in age from neonates to geriatrics. Assignments are dependent upon the specific experience and training of the Case Manager and the needs of the patient.
Must be able to exercise independent discretion and judgment in the performance of the case management functions
Liaison between admitting physician and his office staff, admitting office and the business office, nursing and case managers to facilitate a smooth admission process.
Knowledge of State and Federal regulations; e.g. EMTALA, Medi-Cal, HMOs, etc.
Expert knowledge of InterQual and CERME to make the determination if a patient meets admission criteria.
Demonstrates understanding of Utilization Review process and sound clinical judgment in determining admission status and bed assignment.
Understanding of Medicare, Medi-Cal and other Third Party Payer regulations
Understanding of current utilization/quality management principles, techniques and procedures
Knowledge of current utilization/quality management principles, techniques and procedures
Effective communication in English through reading, writing and speaking
EDUCATION:
Bachelor of Science degree in Nursing degree preferred. RN staff hired on or after April 2023, with an associate degree in nursing are required to be enrolled in an accredited BSN program within 30 days of employment and successfully obtain a BSN degree within four years of the RN hire or reclassification date.
LICENSURES/CERTIFICATION:
Current licensure with the California Board of Registered Nursing
Must successfully complete and maintain LA City Fire Card certification at the time of hire or within the first 30 days of employment
DUTIES AND RESPONSIBILITIES (These are the essential job functions for this position. The essential functions of this job include, but may not be limited to those listed in this job description. Employees hired for this position must be able to perform the essential function of this job without imposing significant risk of substantial harm to the health or safety of themselves or others):
Reviews all hospital admissions to ensure appropriate status and level of care. Uses established Proprietary Medical Necessity screening criteria to review and to determine the medical appropriateness of each hospital admission.
Completes the admission review the in the Proprietary Medical Necessity screening criteria software and documents in the electronic medical health record that admission review was completed.
Communicates as needed with the Admitting Physician and the ER MD, the severity and intensity of illness and the treatment plan of the patient for determination of most appropriate level of care.
Obtains clinical information and completion of a transfer back agreement from facilities requesting transfer for cardiac catheter procedures.
Communicates with physician’s offices, Emergency Department, outpatient surgery and ancillary departments to facilitate assignment of most appropriate patient status and level of care as needed for transfers or requests for VPH beds.
Initiates internal or external Physician advisor referrals for compliance with Medicare inpatient/observation status accuracy, level of care and follows through until final determination is concluded.
Communicates with the PFS and clinical care team to collaboratively achieve effective and efficient admission processes.
Communicates issues regarding utilization, payer requirements, other benefits/services to physicians and others making decisions concerning the patient’s hospitalization and treatment.
Reviews the Observation list daily, monitoring until the patient is discharged or becomes inpatient (i.e.: referrals to EHR, obtaining orders, daily review).
Works closely with ED Charge RN to improve throughput (e.g. monitors tracker for admission orders length of stay on assigned rooms, confers with Pre-Access Case Manager and Charge RN regarding downgrades).
Collaborates with Operations Supervisor on admissions (bed placement, correct location, and need for further clinical information).
Keeps Operations Supervisor updated/informed on potential ICU admissions or special needs with potential ED admits (isolation, trach to vent, and sitter).
Reviews surgery schedule for inpatients, Ortho, ICU, Med/Surg, post op admits.
Attends Dept. meetings and participates in Bed Board Huddles PRN.
Other duties as assigned.
The following job accountabilities are not unique to any particular job but are common to all jobs at VPH:
Complies with VPH policies and procedures on customer satisfaction and service excellence.Demonstrates professionalism and cultural sensitivity in coordinating activities and communicating with all customers, peers, and the community at large.Conducts self in a professional, respectful and courteous manner during all interactions.Works effectively and collaboratively with others toward common goals.
Communicates accurately, honestly, supportively and in a timely manner with department and interdepartmental team members.Demonstrates effective business writing and oral communication skills, handwriting is clear and legible.
Participates in operational aspects of the department, and maintains/participates in performance improvement activities within the department.
Participates in all departmental specific training, Environment of Care (injury/illness prevention, fire/life safety, hazardous materials, emergency preparedness, utilities management, medical equipment management, safety and security management), infection control (standard precautions, TB Exposure Control Plan, Bloodborne Pathogen Exposure Control Plan).
Demonstrates knowledge of and follows safety practices.Understands the importance of safety, including patient safety in the work place.Maintains a safe environment for self and others.
Actively participates in the Patient Safety Program, including event reporting.Identifies sentinel events/near misses and responds per defined organization processes.Participates in education activities and process implementation.Demonstrates advocacy for the patient/customer and appropriately acknowledges patients, customers and visitors.
The above statements reflect the essential functions considered necessary to describe the principle content of the job. They are not intended to be a complete statement of all work requirements or duties that may be inherent in the job.
WORK ENVIRONMENT:
Primarily an inside building/office environment, well lighted and ventilated, which may consist of multiple treatment and/or work sites.
Fast and continuous work pace with variable workload.
Frequent contact with staff and public under a variety of circumstances. Requires ability to communicate clearly (in English) verbally and in writing for effective communication with other staff members, physicians, vendors, community members, patients and patient families, employees and applicants of all socio-economic levels from a diverse cultural and ethnic population.
Subject to many interruptions from multiple calls and inquiries and potentially emotional situations involving accidents, injuries, illness and/or death.
Handles emergency/crisis situations in accordance with Hospital policy.
Answers phones or pages; may carry a beeper/pager, and/or use a two-way radio.
Occasional travel may be required.
Potential risk of exposure to hazards from chemicals (toxic and non-toxic), flammable materials, gas or electrical or radiant energy or equipment with/without moving parts.
PHYSICAL DEMANDS:
Continuous: 66 to 100% of time, Frequent: 33 to 65% of time, Occasional: 0 to 32% of time
Frequent sitting and standing/walking with frequent position change.
Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and chest level.
Occasional/intermittent reaching at or above shoulder level.
Occasional/intermittent bending, squatting, kneeling, pushing/pulling, twisting, and climbing.
Occasional/intermittent lifting and carrying objects/equipment weighing up to 25 pounds.
Continuous use of near vision, hearing and verbal communication skills in handling telephone calls, interacting with customers and co-workers and performing job duties.
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