Nurse case manager job description

1. Facilitates patient’s transfer to capped hospital when admitted to an out of network or out of capped facility and needs continued hospitalization. The nurse follows the Out of Network Transfer Protocol below:

a. The nurse calls the assigned hospitalist where the patient is to be transferred to and lets him/her know that the current attending physician will be calling to discuss continuation of care or vice-versa.

b. The nurse calls the capitated hospital to check if bed is available, provides patient’s demographic information and faxes a face-sheet or pertinent records to the hospital if requested.

c. The nurse checks if MD-to-MD has occurred and once confirmed that the hospitalist has accepted the patient’s transfer and if bed is available, the nurse generates a tracking number for the ambulance.

d. The nurse calls the facility where the patient is being transferred from in order to give the room number assigned for the patient, the phone number for the nurse’s station where the releasing hospital has to call for report and gives the authorization generated for the ambulance.

2. Facilitates Emergency Room (ER) transfers when patients require admission. The nurse assesses and verifies if the patient is stable for transfer to capped hospital, if stable will proceed to Step 1a. If unstable or no bed is available, the nurse gives authorization to admit the patient

3. Documents the specific reason/s why patient is not repatriated back into network or capped facility.

4. Verifies if the attending physician assigned on the case is the correct hospitalist. If assigned attending is not the correct hospitalist, the nurse switches the providers by calling the contracted hospitalist on the case, once accepted, the nurse informs the attending provider that IPA contracted hospitalist will be taking over the case. The nurse e-mails Provider Relations Department of the incorrect attending physician assignment for hospital ER and admitting staff education to ensure correct Hospitalist assignment on future admissions.

5. Coordinates transfers of patients to tertiary facilities for higher level of care.

6. Calls the hospital UR Department to request initial reviews, concurrent reviews and discharge planning for IPA members.

7. Documents clinical reviews in the EZ-cap system.

8. Assigns the appropriate Level of Care (LOC) and approves the authorization if deemed medically necessary using MCG or Inter-Qual (CareEnhance Review Manager Enterprise) guidelines.

9. Identifies unnecessary or aberrant days and forwards the information to the Medical Director and Inpatient UM Manager for final review and determination of potential denial of days.

10. Forwards the case to the Notice of Action (NOA) Coordinator for denial or modification letter generation if final determination is to DENY or modify continued stay. The nurse ensures that the case is closed accurately and documents on Memo Line #2 of EZ cap the number of approved and denied days i.e. Approved 2 days, denied 2 days.

11. Facilitates discharge planning to home, skilled nursing facility, hospice care, etc. Documents discharge disposition on the date of patient’s discharge.

12. Provides authorization for discharge needs i.e. home health care PT, OT, skilled nursing visits, Home infusion, Self-injectable drugs, DME, medical supplies, etc.

13. Reviews and documents clinical reviews of SNF patients at least weekly.

14. Forwards to Disenrollment Coordinator information of SNF patient who is admitted to long-term care and has resided in a nursing facility beyond 30 days. After the month of admission to facilitate disenrollment of member from Managed Care Medi-Cal back to Fee for Service Medi-Cal.

15. Provides authorization for inter-facility ambulance transfers.

16. Attends the daily inpatient meeting to go over daily bed day reports.

17. Reviews and maintains bed day logs weekly and monthly to ensure that Status 7 or pending/open cases are closed timely.

18. Refers potential re-admissions to Outpatient High Risk Case Management for follow-up post discharge.

19. Refers any potential quality of care issues (PQI) identified to the QI Department for review of QI cases.

AmTrust Financial Services, a fast growing commercial insurance company, has a need for a Telephonic Medical Case Manager, RN.
PRIMARY PURPOSE: To provide comprehensive quality telephonic case management to proactively drive a medically appropriate return to work through engagement with the injured employee, provider and employer. Our nurses will be empathetic informative medical resources for our injured employees and they will partner with our adjusters to develop a personalized holistic approach for each claim. These responsibilities may include utilization review, pharmacy oversight and care coordination.
Responsibilities
Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level, are medically necessary and appropriately delivered. Perform Utilization Review activities prospectively, concurrently or retrospectively in accordance with the appropriate jurisdictional guidelines. Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary Responsible for accurate comprehensive documentation of case management activities in case management system. Uses clinical/nursing skills to help coordinate the individual's treatment program while maximizing quality and cost-effectiveness of care including direction of care to preferred provider networks where applicable. Addresses need for job description and appropriately discusses with employer, injured employee and/or provider. Works with employers on modifications to job duties based on medical limitations and the employee's functional assessment. Responsible for helping to ensure injured employees receive appropriate level and intensity of care through use of medical and disability duration guidelines, directly related to the compensable injury and/or assist adjusters in managing medical treatment to drive resolution. Communicates effectively with claims adjuster, client, vendor, supervisor and other parties as needed to coordinate appropriate medical care and return to work. Performs clinical assessment via information in medical/pharmacy reports and case files; assesses client's situation to include psychosocial needs, cultural implications and support systems in place Objectively and critically assesses all information related to the current treatment plan to identify barriers, clarify or determine realistic goals and objectives, and seek potential alternatives. Partners with the adjuster to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim. Engage specialty resources as needed to achieve optimal resolution (behavioral health program, physician advisor, peer reviews, medical director). Partner with adjuster to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards. May assist in training/orientation of new staff as requested Other duties may be assigned. Supports the organization's quality program(s).
Qualifications
Education & Licensing
Active unrestricted CA RN license in a state or territory of the United States required. Bachelor's degree in nursing (BSN) from accredited college or university or equivalent work experience preferred. Certification in case management, pharmacy, rehabilitation nursing or a related specialty is highly preferred. Acquisition and maintenance of Insurance License(s) may be required to comply with state requirements. Preferred for license(s) to be obtained within three - six months of starting the job. Written and verbal fluency in Spanish and English preferred
Experience
Five (5) years of related experience or equivalent combination of education and experience required to include two (2) years of direct clinical care OR two (2) years of case management/utilization management required.
Skills & Knowledge:
Knowledge of workers' compensation laws and regulations
Knowledge of case management practice
Knowledge of the nature and extent of injuries, periods of disability, and treatment needed
Knowledge of URAC standards, ODG, Utilization review, state workers compensation guidelines
Knowledge of pharmaceuticals to treat pain, pain management process, drug rehabilitation
Knowledge of behavioral health
Excellent oral and written communication, including presentation skills
PC literate, including Microsoft Office products
Leadership/management/motivational skills
Analytic and interpretive skills
Strong organizational skills
Excellent interpersonal and negotiation skills
Ability to work in a team environment
Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT
When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Physical: Computer keyboarding
Auditory/Visual : Hearing, vision and talking
Not ready to apply? Connect with us for general consideration.

** Position includes a $5k Sign-On Bonus. **

MSA Hospice , a division of Medical Services of America, Inc., currently seeks a Full-Time Registered Nurse Case Manager for our Hospice patients in Augusta, GA.

• Provides services requiring substantial and specialized nursing skill, in accordance with the plan of treatment signed by the physician and makes the initial evaluation visit to the client.
• Regularly reevaluates the nursing needs of the client; initiates, develops, implements and makes necessary revisions to the client’s plan of care.
• Initiates diagnostic, preventive and rehabilitative nursing procedures as appropriate to the client’s care and safety.
• Observes, records and reports the client’s reaction to treatment and any change in the client’s condition.
• Teaches, supervises and counsels the client and family regarding home nursing procedures and other care needs as appropriate to the client’s condition.

Qualifications and Skills

• Completion of a nursing program from an accredited school or university required.
• Must be currently licensed as an RN in the state of GA.
• Minimum of one-year nursing experience required.
• Hospice experience strongly preferred.
• Valid Driver's License required.

MSA offers competitive pay and excellent benefits:

• Generous paid time off
• Medical/Prescription, Dental & Vision Insurance and other benefits (STD, LTD, Accident & Sickness, additional life insurance, etc.)
• Company paid employee life insurance
• 401(k) retirement with a generous company match
• Opportunities for advancement
• Many other great benefits

MSA is an Equal Opportunity Employer

Visit us at www.medicalservicesofamerica.com

Company DescriptionMedical Services of America began with a unique concept, "total home health care," and its expansion has been guided with that concept in mind. MSA is now a comprehensive home healthcare provider that offers home healthcare, hospice care, home medical equipment and supplies, diabetic supplies, respiratory services, mail order supplies, enteral nutrition therapy, senior/assisted living and physician practice management.