Chronic Care Manager, Pop Health and Value Based Care - Full Time, Days (CORP - Los Angeles)

The RN Case Manager is responsible for performing clinical assessment and reassessment of acute care Inpatients for the purpose of performing utilization review, resource management and safe discharge planning.  The RN Case Manager prioritizes, plans, organizes, and implements timeliness of care. Collaborates with the interdisciplinary healthcare team to promote and coordinate the delivery of safe and cost-effective patient care, transition of care and discharge planning. The RN Case Manager advocates for patient self-determination and choice. Practices clinical competence in evaluations and planning with awareness and respect for patient and family diversity. Monitors and coordinates resource utilization throughout the continuum of care and evaluates timeliness of services. Performs admission, continued stay and discharge review utilizing medical staff-approved decision support criteria. 

•            Collaborates as needed with the patient and family to optimize client outcomes. May include work with community, local and state resources, primary care provider, and members of the health care team, payer, and other relevant health care stakeholders to facilitate appropriate patient transfers, discharges and transitions of care. Identifies timely and effective alternative lower level of care settings for patient care in accordance with the patient’s medical necessity, stability, the patients’ preferences and health plan benefits. Identifies timely post-hospital needs and arranges for services as appropriate. Provides patient and family appropriate resources and/or referrals. Makes timely and appropriate referrals to, and seeks consultation with others when needed, the patient-centered provision of services; such as Social Services (i.e., Durable Power of Attorney).

•            Reviews medical necessity utilizing medical staff-approved evidence-based decision support criteria.  to determine appropriate level of care and length of stay. Ensures utilization review is completed and documented concurrently, and provided to the patient’s payer as required.  Ensures timely escalation of unresolved care coordination issues to the appropriate level. Enters delays in service and avoidable days regarding exceeded payer LOS variances. Communicates denials and physician related utilization management practices to immediate supervisor same day as identified.

•            Collaborates with patients/caregivers to set goals consistent with physician treatment plans, and patient resources and choices. Collaborates with the multidisciplinary team for timely discharge planning assessments and reassessments and documents concurrently in the patient's medical record in compliance with hospital policy and all regulatory agencies.  Provides appropriate instructions to discharge care coordinators as needed. 

•            Acts as an effective liaison to medical staff to ensure continuity and congruity of hospital services in accordance with the patient’s plan of care.

•            Participates in patient and family meetings; respecting and promoting patient choice and documents informed decision making. Utilizes knowledge of psycho-social and physical factors that affect functional status on discharge.

•            Contributes requested data for the Utilization Management Committee.

Required Qualifications: 

• One year of case management experience or 1 year nursing leadership experience
• Current Licensure as a Registered Nurse in the State of California
• Computer/EMR Proficiency and Literacy
• Knowledge of CMS, Medicare, Medi-Cal and Managed Care reimbursement
• Familiarity of Joint Commission, CMS, CDPH requirements
• Excellent written and verbal communication skills in English
• Ability to establish and maintain effective working relationships across the organization
• Ability to facilitate and lead interdisciplinary rounds

Preferred Qualifications: 

• Bachelor of Science in Nursing 
• Certified Case Manager (CCM)
• Familiarity with AllScripts Care Management
• Proficiency with Milliman Care Guidelines or Interqual
• Bilingual skills to communicate effectively with patients and families

Pay Rate: Min - $120,000 | Max - $165,000

Prospect Medical Holdings' ability to deliver quality, compassionate care during the unprecedented pandemic affirms the original vision of its founders. This is the fulfillment of the hopes Prospect’s founders had for the company, and proof that a clear vision, an insightful operating model, and a commitment to communities and our employees, born in the past, remains the way of the future.
Every day, our more than 11,000 affiliated physicians and 18,000 employees at 17 hospitals, 165 outpatient centers and 28 medical groups provide nationally recognized care in six state