Readmission Case Manager

Summary Under the direct supervision of the Leads & RN Clinical Manager for Case Management, the Readmissions Case Manager is responsible for assessing, planning, implementing monitoring and evaluating options and services to develop a patient focused action plan for their identified cohort of patients.
They act as patient advocate through the continuum and is available to the physician, patient, and family as a resource to facilitate communication.
As patient advocate, he/she also monitors patient care to ensure that the patient receives quality care using standards of care and practice guidelines.
Duties and Responsibilities: Performs medical, functional, safety, nutritional and psychosocial assessments on targeted assigned caseloads to evaluate the member’s needs and coordinate appropriate care.
Case management of the targeted cases should be problem focused and address risks.
Documents and defines the issues, problems and appropriate interventions and include follow-up evaluations.
Provides open, sensitive timely communication with patients, families, and their significant others to participate in the patient’s care.
Exhibits diverse understanding and can interface effectively with all employees, members, employers, MPM personnel and providers.
Recommends enhancements and/or changes that would improve the existing program.
Participates in the Interdisciplinary Care Team (ICT) Meeting as they relate to his/her target cases.
Participates in tracking, analyzing, and reporting of information on cases assigned for the specific PPG/IPA.
Maintains effective communication with managed care plans, physicians, hospitals, extended care facilities, members, MPM contracting department, and co-workers concerning the referral process.
Assists in coordinating services for high cost/ high utilization cases as the resource manager so members obtain appropriate outpatient services to minimize inpatient utilization.
Assists in the preparation of Health Plan audits in a timely fashion.
Perform or assume other duties as assigned.
Assist with orientation and training for new employees as needed.
Minimum Job Requirements: Current California RN/LVN License 1-2 years Acute Care experience 1-2 years’ experience in Basic/ Complex Case Management a plus 1 year experience in Managed Care Working knowledge of the Standards of Practice for Case Management and the ability to implement the standards of practice in the day-to-day interaction with the members.
Minimum one (1) or more years of experience as a referral authorization coordinator/ specialist in an IPA/ Medical Group or Health Plan setting.
Must be computer literate with basic office and computer skills.
Skills and Abilities Required: Bilingual is a plus EZ-CAP knowledge a plus.
Detail oriented and possess communication skills, both verbal and written Salary Range: $35-40 hourly