The Case Manager, RN conducts case management on patients in the inpatient, intensive outpatient, residential care and Skilled Nursing Facility settings. The Medical Network has developed a case management program that is geared towards the management of patients while hospitalized and upon discharge from various care settings. Using the Case Management Society of America's (CMSA) model, we describe our approach as "a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes." In collaboration with the Inpatient Specialty Program (ISP) hospitalists (physicians who practice hospital medicine), the program is crafted to assist patients from the time they are admitted until they are discharged from the hospital by assessing their needs, coordinating care, communicating with health plans (including concurrent review, which assists the hospitalist/specialist and case manager to determine the appropriateness of services rendered and to ensure that quality care is delivered in a cost-effective manner), and referring to disease management programs and ambulatory case management (focus is on those members requiring complex and/or chronic care for follow up after discharge). Decisions regarding care are made within one working day of acquiring all vital information.
Primary Job Duties and Responsibilities
Care Manager meets with patients within 24 hours of admission and conducts an initial assessment.
Consults with assigned hospitalist every single day during morning rounds regarding disposition planning and appropriateness for every single day of patient's stay
Reviews with hospitalist the patient's admission and continued stay for medical necessity, appropriateness of care and level of care. Use Milliman and Interqual guidelines.
Begins discharge planning and care assessment within one working day (preferably on day of admission).
Submits vital clinical information to the health plan using the accepted format (MIDAS or telephonic) and coordinate health plan communication with assigned hospitalist as appropriate.
For patients who are transitioning to the Skilled Nursing Facilities, refers to nurse practitioner and case manager assigned to the SNF's for continued review and follow up.
Case Manager will wear employee badge: all rules and policies of the facility will be followed while on-site.
If admission is to a non-contracted facility, determine if patient is stable for transport and transfer back in-network.
Authorize all appropriate services based upon covered benefits and necessity of care provided.
Coordinate discharge planning and alternative treatment plans with PCP/hospitalist/specialist as appropriate.
After hours, the on-call case manager support that is an invaluable resource to both the patients and the physicians.
Coordinates the patient's care with other health care personnel to ensure that the patient receives care timely post discharge.
Secures outpatient follow-up appointments and scheduling tests or outpatient procedures with appropriate health care providers
Referrals to Ambulatory Case Manager for those patients identified that will need oversight of outpatient care and compliance to avoid unnecessary readmissions
Coordinates referrals and secure appointment with disease management programs such as anticoagulation clinic, Asthma, Diabetes, Hepatitis C, smoking cessation, cardiovascular risk reduction and nutrition, as appropriate
Enters and updates all authorization and clinical information into Nautilus (Access Express) no later than date of discharge.
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major t...eaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.