Care Manager, Registered Nurse

We are so glad you are interested in joining Sutter Health!

Organization:

SMCS-Valley Administration

Position Overview:

Responsible for Care Coordination and Care Transitions Planning throughout the acute care patient experience. This position works in
collaboration with the Physician, Utilization Manager, Medical Social Worker and bedside RN to assure the timely progression and transition
of patients to the appropriate level of care to prevent unnecessary admissions or readmissions. The Care Management process
encompasses communication and facilitates care across the continuum through effective resource coordination. The goals of this role are to
include the achievement of optimal health, access to care, and appropriate utilization of resources balanced with the patients' self
–determination while coordinating in a timely and integrated fashion. He/She collaborates with patients, families, physicians, the
interdisciplinary team, nursing management, quality, ancillary services, third party payers and review agencies, claims and finance
departments, Medical Directors, and contracted providers and community resources. If assigned to the Emergency Department, the Care
Management process is to address complex clinical and social situations efficiently in order to avoid unnecessary admissions.
These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job.
Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job
change (for example, emergencies, staff changes, workload, or technical development).
JOB ACCOUNTABILITIES:
Patient Initial and Continued Assessment.
• Reviews initial physician admission care plan. Gathers additional medical, psychosocial, and financial information from the patient/family
interview, medical record assessment, physicians, and other health care providers. Determines moderate or high risk level for readmission.
Conducts a screening for ancillary supportive services, including but not limited to Palliative Care Services’ needs.
• Functionally supervises and actively leads the health care team in developing comprehensive cost-effective care coordination plans that
meet the clinical needs of our patients.
• Identifies and refers quality and risk management concerns to appropriate level for patient safety reporting and trending.
• Directs and oversees the Case Management Assistants to determine preferences for post-acute care services.
Utilization Management.
• Reviews medical record to ensure patient continues to meet level of care (LOC) requirements and that chart documentation supports LOC
determination and assignment.
• Works with Attending Physicians to confirm necessary documentation to support level of care (LOC).
• Expedites transition planning for patients who no longer require acute level of care.
• Monitors length of stay (LOS) and outliers requiring additional resources and/or focus.
• Collaborates with financial counselor for delivery of inpatient stay denials.
• Assures delivery of Medicare Important Message within 48 hours of discharge/transition and no less than 4 hours of actual
discharge/transition.
• Actively participates in patient rounds following the standard work as developed and collaborates with interdisciplinary team to assure
timely transition.
• Follows policies and procedures for Physician Advisor referrals.
• Utilizes appropriate escalation process when discussing level of care (LOC) requirements with providers.
• Consistently documents in the EHR and other electronic software.
• Maintains current knowledge of CMS and Joint Commission Transitions of Care requirements, Conditions of Participation (COPs), and
other regulatory requirements.
• Effectively follows Observation patients, re-evaluates and collaborates with attending physician for admission or transition to appropriate
level of care for the patient.
Care Coordination/ Care Transitions.
• Formulates a transition plan after reviewing available/appropriate care options and obtaining input, and collaborating with the patient/family
and physician, health care team, payers, and community based support services.
• Performs, documents, and communicates assessment findings to health care team.
• Screens 30-day readmissions; reviews previous hospital record confers patient/family and with interdisciplinary team to create an effective
and realistic transition plan.
• Proactively identifies barriers to care progression and transition, and works with multi-disciplinary team to resolve timely.
• Addresses complex clinical and social situations efficiently in order to avoid unnecessary admissions, improper level of ca