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Skilled Nurse Facility Case Manager in Orange at Prospect Medical Systems

Date Posted: 10/16/2018

Job Snapshot

Job Description



Skilled Nurse Facility Case Manager

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Skilled Nurse Facility Case Manager is responsible for the coordination of services for patients currently receiving skilled services or residing in long-term care (LTC) facilities.



Job Responsibilities/Duties

  • Effectively manage patients either telephonically or on-site to ensure the appropriate level of care is efficiently provided for Prospect patients. Communicates effectively with facility staff, hospitalist / nurse practitioner, family / caregiver as needed. Provides timely and accurately responses to request information and/or provides authorizations to facilitate appropriate discharge planning.
  • Communicates with hospitalists, interdisciplinary teams and patients to evaluate plan of care including discharge planning. Authorizes appropriate outpatient services using current criteria (Milliman [MGC] CMS and Title 22 guidelines).
  • Update clinical information in the appropriate electronic medical record with treatment plan.
  • Applies appropriate benefits and informs patient and family / caregivers as needed.
  • Actively participates in weekly rounds. Present current patient information to facilitate discussion of discharge plans and continuity of care needs.
  • Effectively manage an average census of 65 SNF and LTC (custodial) patients at any given time.
  • Provides after-hours, on-call coverage via a pager as assigned.
  • Refers cases to the Medical Director as a appropriate for denial of stay or review of potential observation status.
  • Identifies and refers cases not meeting outpatient service authorization criteria and provides clinical information and rationale to the Medical Director for review and determination.
  • Provides denial letter language and member / provider notification regarding Medical Director's review determination. Completes 1st level response to appeals.
  • Identifies and refers appropriate cases to High Risk, Hospice / Palliative, or other program resources in accordance with Prospect policies and procedures, and documents referral in case file.
  • Identifies and reports under and over utilization of medical services, delays in service by provider or hospital or treatment and quality and work flow enhancement projects, and other duties, as assigned. Identifies and reports departmental operational issues and resource needs to the appropriate management personnel.


Qualifications

Minimum Education:  RN / LVN active unrestricted license in the state of Prospect operations with three to five (3-5) years of experience in a medical group or Health Plan Setting with strong clinical skills and critical thinking required. 

Minimum Experience: At least four (4) years of concurrent review experience, preferably in a managed care setting.

Req. Certification/Licensure: RN / LVN license.



Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance


How to Apply

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm

Keywords: Skilled Nurse Facility Case Manager, LTC, Facilities. 



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