• Analyzes requests with the objective of monitoring utilization of services, this includes medical appropriateness and identifying potential high cost, complex cases for outpatient case management intervention.

• Reviews and evaluates proposed services utilizing medical criteria and/or established policies and procedures.

• Determines the appropriate action for the service being requested for approval, modification or denial, and refers to the Medical Director for review when necessary.

• Reviews inpatient setting requests to determine if surgery and/or medical care is appropriate.

• Identifies diagnosis and determines need for continuing hospitalizations; monitors the inpatient length of stay as per established guidelines and professional judgment.

• Initiates contact with patient, family, and treating physicians to obtain additional information or to introduce the role of case management as needed.

• For short-term cases, conducts a thorough and objective assessment of the member’s status including physical, psychosocial and environmental.

• Develops, implements and monitors a care plan through the interdisciplinary team process in conjunction with the individual member and family in internal and external settings across the continuum of care.

• Provides cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.

• Assesses member’s status and progress; if progress is static or regressive determines reason and encourages appropriate referrals to out-patient case management or make appropriate adjustments in the care plan, providers and/or services to promote better outcomes.

• Establishes means of communication and collaboration with other team members, physicians, community agencies, and administrators.

• Prepares and maintains appropriate documentation of patient care and progress within the care plan.

• Acts as an advocate in the client’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.

• Collaborates with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem and solving complex cases.

• Documents clinical information into the case notes along with the rationale for all decisions in the Guiding Care system.

• Other projects and duties as assigned.

Experience & Education:

• Minimum High School diploma, Associate’s degree preferred.


• Current LVN license to practice in the State of California is required.


• 3 years of nursing experience required, 1 year of which must be as a nurse reviewer.
  
  

Preferred Qualifications:

- 1 year of Concurrent Review (in-patient) experience.

Knowledge of:

• Guidelines and regulations relevant to case management and utilization management.


• Understand confidentiality and the legal and ethical issues pertaining to case management.


• ICD-9/ICD-10 and CPT coding requirements.


• Available community resources.


• Effective charting practices and guidelines.


• Available medical treatments and resources.


• Principles and practices of health care, health care systems, and medical administration.