RN, MSN Transitional Case Manager - Medical Group

Location: San Francisco, CA
Date Posted: 02-01-2018
Transitional Case Management (RN, MSN or NP) - Managed Care
San Francisco, CA
Your Job Summary:
Responsible for safely and effectively transitioning members from acute or inpatient care to lower levels of care, or return to their home, in a cost efficient manner.  Provides assessment, planning, implementation, coordination, monitoring, and evaluation of services for members as they transition care and follows them for roughly 30 days post discharge.  Conducts regular assessments, either in person or telephonically, of the member’s ongoing health status, at a minimum conducting a pre-discharge visit with the member or their designee, and a post discharge discussion with the member.  Perform outreach to members to assess post discharge needs and coordinate outpatient care as necessary in order to assure continuity of care and prevent unnecessary readmissions.
Your Reward: 
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health. 
Your Background:
Valid, unrestricted state Registered Nurses (R.N.) license. 
Must have advanced practice certification, Advanced Registered Nurse Practitioner (A.R.N.P.) or Masters prepared RN.
Relevant Certifications (CCM, CDMS, CRC, CRRN, CHON, or CPUR/CPUM/CPHM) are preferred.
Roughly 3-4 years acute care clinical nursing experience.
Around 1-2 years’ experience in a Managed Care Organization (Health Plan/HMO/MSO/TPA/IPA/etc).
At least 1-2 years’ experience with case management, or care coordination; inpatient settings preferred.
Must have strong (2+ years) discharge planning experience involving patient/family education.
Background in discharge planning with some exposure to home healthcare is highly desirable.
Experience working with Federal and State assistance programs (Medicare/Medicaid/etc)
Computer literacy (MS Office) and typing skills are necessary.
Prefer prior experience with, CCMS, Interqual, CERME, Milliman, or other healthcare databases.
Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
Your Duties:
The Nurse Case Manager will serve the case management needs of members as the transition from an inpatient setting to an outpatient setting.  Facilitates transition of care between inpatient and other settings with the practitioner, health plan staff, community based agencies, social workers, hospital or nursing facility discharge planner, and other providers as required.  Coordinates necessary services with public agencies and participating ancillary service providers as appropriate to ensure quality and cost effective care that promotes reduced readmissions.  Develops and implements a post discharge care plan consistent with sound medical, behavioral health, chemical dependency, and financial management that includes an assessment of health needs, individualized care or service plans, and monitoring for evaluation of case outcomes.  Reviews and updates care plans for continuity of care and facilitates plan modifications, including barriers to identified goals and interventions for members being coached through the transition of care.
Coordinate and communicate discharge planning needs with appropriate internal and external entities. Analyze patterns of care associated with progression to severe disease; identify contractual services and organize delivery through appropriate channels. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, and Mental Health and Substance Abuse care coordination.  Identify members who may benefits from internal programs such as case management.   Refers complex cases to case management as appropriate based on consultation with the Interdisciplinary Team.
Identify and document quality of care issues and resolve or route to appropriate area for resolution. Follow out-of-area and out-of-network inpatient services and make recommendations on patient transfer to in-network facilities or alternative plans of care.  Develop and deliver education for provider community regarding policies, procedures, benefits, co-pays, etc. and other medical management programs.  Provide effective and culturally sensitive communication with individuals and families from diverse ethnic and cultural backgrounds.
Rafik Henderson
CareNational Healthcare Services
480.646.3544 (CALL – TEXT – FAX)
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