Outpatient Case Manager (RN)

Regal Medical Group•Covina, CA

13h•$45 - $50

About The Position

The Outpatient Case Manager is responsible for assessing, planning treatment, implementing interventions, monitoring, evaluating, and documenting outcomes for identified High-Risk members. The Outpatient Case Manager will assess and develop a care plan in collaboration with the admitting, attending, and consulting physicians, the member, and other health care practitioners. The goal of the Outpatient Care Manager is to effectively manage members on an outpatient basis to assure the appropriate level of care is provided, to prevent inpatient admission and re-admissions, and ensure that the members’ medical, environmental, and psychosocial needs are met over the continuum of care. This role will support the DSNP Regulatory line of business, which serves high -risk dual members who require care coordination, transition of care support ,and on-going monitoring.

Requirements

Graduate from an accredited Registered Nursing.
Current CA RN license and current CPR certification.
3 years acute care or case management experience preferred.
2-3 years of utilization or HMO experience preferred.
Knowledge of computers, faxes, printers and all other office equipment.
Typing 30 WPM with accuracy. Proficient in MS Office Programs (i.e., Word, Excel, Outlook, Access and PowerPoint).

Responsibilities

Keeps member/family members or other customers informed and requests, if necessary, further assistance when needed.
Demonstrates the ability to follow through with requests, share critical information, and get back to individuals promptly.
Functions as liaison between administration, members, physicians, and other healthcare providers.
Interacts professionally with families/physicians and involves members/families/physicians in the formation of the plan of care.
Performs a Clinical Assessment/Questionnaire of the member and determines an acuity score for necessary scheduled follow-up.
Develops an outcome-based plan of care, based on the member’s input and assessed member needs. Implements and evaluates the plan of care as often as needed, as evidenced by documentation in the member’s case file.
Documents member assessment and reassessment, member care plans, and other pertinent information completed in the member’s medical record in accordance with the FOCUS Charting methodology, nursing standards, and company policies and procedures.
Initiates community visits (hospital, home visits) as needed to assess patient progress and meet with appropriate members of the patient care team.
Identifies planned and unplanned transitions of care from Requests for Services or daily inpatient and SNF census.
Educates the member/caregiver on the transition process and how to reduce unplanned transitions of care.
Manages transition of care from the sending to receiving settings, ensuring that the Plan of Care moves with the member and updates/modifies the care plan as the member’s health care status changes.
Communicates appropriately and clearly with physicians, inpatient case managers, and Prior-Authorization nurses
Identifies and addresses the psychosocial needs of the members and family and facilitates consultations with the Social Worker, as necessary.
Identifies and addresses the pharmacological needs of the members and facilitates consultations with the pharmacy department, as necessary.
Identifies community resources to address needs not covered by the member’s benefit plan, and coordinates member benefits as needed, with the health plan.
Participates in the efficient, effective, and responsible use of resources such as medical supplies and equipment.
Responsible for the coordination and facilitation of member and family conferences as determined by assessment of the member’s needs.
Identifies the appropriate members to participate in the interdisciplinary case round process. Prepares the necessary summary information to present to the team.
Responsible for the coordination of clinic appointments, medication reconciliation, PCP, and SPC visits.
Ability to collaborate and communicate with all members of the healthcare team (concurrent review, pre-authorization, PCP/SPC, Social Services, and Pharmacy) to coordinate the continuum of care and develop plans for management of each case.
Responsible for identifying members who are appropriate for hospice conversion or Palliative care.
Meet with members/caregivers face-to-face in different locations (clinic, home, hospital, and community) in order to build a rapport with members so that the case manager can better support members/caregivers with care coordination and the plan of care.
Other duties as assigned by management.