The RN Case Manager (RNCM) facilitates utilization management (UM) processes to support that the right care is provided at the right place and at the right time. To accomplish these goals, the RNCM applies established criteria to evaluate the appropriateness of admission, level of care, continued hospitalization and readiness for discharge (DC); assures timely movement of patients throughout the continuum of care by conducting concurrent review and proactively resolving care, service or DC delays / issues as necessary; proactively assessing post-DC needs and developing and implementing case management plans; providing third-party payers clinical information to assure reimbursement; and coordinating care with the treatment team, patient, family and others as necessary.
The Resource UM Department at Memorial Medical Center (MMC) embraces the Scope of Services adopted by the American Case Management Association which states:
“Case Management (CM) in Hospital and Health Care Systems is a collaborative practice model including patients, nurses, social workers, physicians and other practitioners, caregivers and the community. The CM process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of CM include the achievement of optimal health access to care and appropriate utilization of resources, balanced with the patient's right to self-determination.“
This position will serve to support UM needs on inpatient units and/or the emergency department (ED). Shift hours are based on location of primary work unit.
Serving the greater Stanislaus County with 423 plus acute care beds, Memorial Medical Center provides a full continuum of care including 24-hour emergency care, inpatient and outpatient surgery, obstetrics, pediatrics, nuclear medicine, dialysis therapy, diagnostic imaging, intensive care, physical therapy, and home health. Specialized care includes Memorial Regional Cancer Center and Memorial Heart Institute.
- Graduate of accredited school of nursing with a current valid licensure as a Registered Nurse in the State of California
- Minimum of three (3) years' experience, as an RN, in direct patient care delivery and / or management. Preferred patient care areas would be the emergency department, ICU or telemetry or successful completion of MMC's Clinical Nurse Resident (CNR) program for Case Management.
- Demonstrates basic knowledge of the role of UM, DC Planning and / or CM for patients within an acute hospital and / or ED setting and across the continuum of care. This will be assessed during the interview process and the candidates narrative answers to case scenarios.
- Demonstrated ability to efficiently and independently manage own time and tasks with minimal supervision.
- Excellent verbal and written communication skills required. Must be able to communicate effectively with a wide variety of personalities and departments, including members of the medical staff.
- Ability to read, write, hear, and communicate verbally in English to the degree required to perform the job.
- Willingness to act and dress in a professional manner at all times. Proficient in using a computer to accurately enter and extract data, send and receive email, calendar appointments, and use task lists as will be using a variety of computer software programs. Must be able to travel in and out of Stanislaus County, including transcontinental travel. If MMC and/or own vehicle used on company business, must possess valid California Driver's License and upon request proof of liability insurance.
- Recent experience as an UM Coordinator and CM in DC Planning in an ED or acute care hospital setting.
- Knowledge of UM tools such as InterQual or Milliman criteria.
- Bachelors of Science in Nursing (BSN).
- Certification in ACMA, CCM, CPUR.
- Ability to use Microsoft Office Suite products (Outlook, Word, Excel, Power Point).
- Experience with MIDAS and EPIC systems