Case Manager Specialist - Utilization Management (1.0 FTE, Days)
1.0 FTE, 8 Hour Day Shift
At Stanford Children’s Health, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.
This paragraph summarizes the general nature, level and purpose of the job.
Case Manager Specialists are licensed nursing professionals responsible for coordinating continuum of care and discharge planning activities for a caseload of assigned patients in a service line, and subject matter expert that represents the department, the organization and the company at internal and external venues. Major responsibilities include coordinating all facets of a patient's admission/discharge; performing utilization review activities, including review of patient charts for timeliness of services as well as appropriate utilization of services; and ensuring optimum use of resources, service delivery, and compliance with external review agencies' requirements. Identifies and standardizes the case management role. Case Managers act as consultants to the clinical team, service lines, and other departments regarding patient assessment and patient care and participate in program development and quality improvement initiatives. In their role, Case Managers, by applying guidelines and collaborating with multidisciplinary teams, influence and direct the delivery and quality of patient care. A hospital-based case management system has as its primary goal to ensure the most appropriate use of services by patients and, toward that end, to avoid duplication and misuse of medical services, control costs by reducing inefficient services, and improve the effectiveness of care delivery. Objectives are to facilitate timely discharge; prompt, efficient use of resources; achievement of expected outcomes; collaborative practice; coordination of care across the continuum; and performance/quality improvement activities that lead to optimal patient outcomes. The Case Manager Specialists assist in mentoring staff to elevate their professional development and effectiveness. Performs individual gap analysis training assessments, research industry-wide best practices and identifies professional certification opportunities. Mentors staff to elevate their professional development and effectiveness. Collaborates with interprofessionals and external organizations, and through planning, developing and coordinating educational opportunities. A Case Manager differs from other roles in professional nursing/health care practice in that it is not intended to provide direct patient care; rather, a Case Manager will be assigned to specific patients to ensure that the medical services and treatments required are accomplished in the most financially and clinically efficient manner.
The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.
Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.
Must perform all duties and responsibilities in accordance with the Service Standards of the Hospital(s).
COORDINATION OF CARE
Manages each patient's transition through the system and transfers accountability to the appropriate person upon entry into another clinical service or discharge.
Patient care needs always take precedent over any education/quality improvement needs of the department.
Coordinates and facilitates timely implementation of discharge plans for assigned patients with complex needs in collaboration with other interdisciplinary team members; arranges follow-up care as appropriate.
Acts as an educational resource and provides consultation to patients and their families, hospital medical personnel regarding the discharge planning process and applicable regulatory requirements; educates the staff on case management; and provides specific information related to case types.
Collaborates directly with the manager and director to identify and standardize case management role expectations and levels of competency for the department.
Assists in mentoring staff to elevate their professional development and effectiveness through collaboration with interprofessionals and external organizations, and through planning, developing and coordinating educational opportunities.
Participates in quality improvement activities by identifying opportunities for improvement in such areas as clinical outcomes, utilization of resources and concurrent data collection; participates in clinical process improvement teams within the department, service lines, and hospital.
Under the guidance and direction of Case Management leadership, performs individual gap analysis training assessments, research industry-wide best practices and identify professional certification opportunities.
Elevates the professional practice and redefine the boundaries of traditional case management.
May lead the work of administrative/clinical support staff responsible for assisting with case management for an assigned patient caseload.
Participates in department program planning, goal setting, systems development and process improvement; participates in department and hospital committees and task forces; develops and maintains documentation of findings, discharge arrangements, and actions taken according to departmental guidelines; prepares and maintains records as required; collects, analyzes and reports on data for utilization, quality improvement, compliance, and other areas as assigned.
PATIENT ASSESSMENT / PLAN OF CARE
Functions as a resource to and collaborates with physicians, social workers, nurses, and other interdisciplinary team members to assess, plan, and coordinate patient care needs and/or performs patient assessment and develops a plan of care to assure consistent, timely, and appropriate care is provided in a patient-focused manner.
Collects, analyzes, reports and reviews patient information with third-party payors to assure reimbursement for patient services/procedures. Communicates with review organizations/payers to provide requested clinical and psychosocial information to assure reimbursement.
Reviews prospectively, concurrently and retrospectively all inpatients for appropriateness of admission, level of care, and determines appropriate length of stay.
Monitors patients' length of stay and collaborates with physicians to ensure resource utilization remains within covered benefits and are appropriate in relationship to the patient's clinical and psychosocial needs; plans and implements (through multi-disciplinary meetings or rounds) strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes analyzes and addresses aggregate variances as well as variances from individual patients and shares this information with staff, physicians, and administration.
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
Education: Master's Degree in Nursing from an accredited college or university
Experience: Two (2) years of progressively responsible and directly related work experience
License/Certification: CA Registered Nurse (RN)
Knowledge, Skills, and Abilities
These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.
Ability to collect and record data, evaluate data and statistics, and maintain effective reporting systems.
Ability to develop and perform patient assessment and plan of care.
Ability to monitor and assure the patient's access to the appropriate level of care; the right health care providers; and the correct setting and services to meet the patient's needs; promote coordination and continuity in patient health care.
Ability to provide age-appropriate assessments, interpretation of data, and delivery of interventions.
Ability to provide appropriate patient care and clinical information when patients are admitted, referred, transferred, or discharged.
Ability to remain knowledgeable regarding available treatments and services.
Ability to resolve conflicts and/or negotiate with others to achieve positive results; establish and maintain effective interpersonal relationships.
Ability to understand, interpret and apply complex federal and state hospital compliance laws, rules, regulations and guidelines.
Ability to work effectively with individuals at all levels of the organization.
Knowledge of available patient services and treatment.
Knowledge of current theories, principles, practices, standards, emerging technologies, techniques and approaches in the nursing profession, and the health care system, and the responsibility and accountability for the outcome of practice.
Knowledge of evaluation and assessment techniques.
Knowledge of financial processes of various private and public funding sources for health care services/procedures.
Knowledge of hospital operations, organization, systems and procedures and laws and regulations pertaining to the operation of hospitals in California.
Knowledge of medical terminology and related levels of care and treatment.
Knowledge of the full continuum of care available to patients, interrelationships of the care components, and their effective integration.
Knowledge of the models of case management, including the principles and practices of discharge planning, utilization review, and quality assurance/improvement
Knowledge of the variables that affect the processes and outcomes of patient health care.
Physical Requirements and Working Conditions
The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.
Equal Opportunity Employer