Case Manager (Psych - UR) - Full Time, Days (Culver City) at Prospect Medical Holdings, Inc. in CULVER CITY, California

Job Description:

The RN Case Manager, UR is responsible for overseeing the daily operations of the assigned caseload. Ensures Medical Necessity for patient admission and concurrent stay at the short-term acute hospital level of care are met, utilizing the facility approved non-MD reviewer guidelines. Communicates as appropriate to the payer. Refers all cases not meeting MN for second level review. Ensures a safe and timely discharge / transition to the next appropriate level of care. Ensures timely escalation of unresolved care coordination issues to the appropriate level/entity. Enters delays in service and avoidable days regarding exceeded payer LOS variances. Communicates denials and physician related utilization management practices to immediate supervisor same day as identified. Keeps facility administration and Director of Utilization Management aware of any daily operational / physician related issues. Works closely with the facility Physician Advisor. Works collaboratively with health care team, patients and families, administration and members of the Medical Staff. Responsible for active participation in daily weekday intra disciplinary patient rounding.Southern California Hospital at Culver City has been taking care of generations of Culver City and west LA residents. We are a full-service, acute care hospital with a 24/7 emergency department and nationally recognized patient safety. Now at 420 beds, SCH-CC is a general acute care hospital that utilizes many of the latest medical treatments and technologies. The hospital offers a wide range of inpatient and outpatient acute care services, including an orthopedic center, cardiovascular services, acute rehabilitation, sub-acute care, psychiatric care and chemical dependency programs. Additionally, SCH-CC operates a 24-hour emergency services center, which serves as a paramedic receiving station and is staffed by board-certified emergency physicians and nurse specialists. \n
\n
\n
\n
Union Pay Info: https://www.pmh.com/schccunion-8hr/ \nRequired Qualifications:

• Current Licensure as a Vocational Nurse in the State of California


• Two (2) years of experience in utilization review/management in a managed care or hospital setting.


• Knowledge of The Joint Commission and Title XXII regulations


• Knowledge of CMS, MCARE, MEDI-CAL and Managed Care Reimbursement.


• Knowledge in insurance authorization and verification


• Knowledge of Interqual and /or Milliman Care criteria


• Excellent written and verbal communication skills in English


• Computer/EMR Proficiency


• AHA Basic Life Support


• De-escalation certification upon hire; Upon recertification, SAMA Certification required


• Hospital Fire and Life Safety Card (Los Angeles City Employees only)

• Three (3) years clinical experience in psychiatric hospital setting.


• Care Management Proficiency with Milliman Care Guidelines or Interqual

• Works collaboratively with LVN Case Manager, UR to complete TARs for assigned Medi-Cal patient population and obtains authorizations for managed care accounts and submits appeals for all denied cases. Oversees process and ensures that work is completed daily and in a timely manner. Demonstrates problem-solving, critical thinking, and prioritization of work to resolve issues as they arise. Maintains confidentiality of all information according to Hospital Policy and Procedure and legal and regulatory requirements.


• Reviews hospital admissions and continued stays in accordance with procedures, criteria, and standards approved by the medical staff. Identifies opportunities for improvement in the current processes and procedures. Escalates unresolved issues to direct supervisor or UM Facility Administrator per escalation process.


• Collaborates with Social Services, Clinical Team, patient and families to prepare patient's discharge planning needs. Oversees appropriate DC documentation. Works with Social Service to perform a variety of miscellaneous services, such as arranging for discharge or post-hospital plans, placement of patients in skilled nursing facilities or board and care homes.


• Collects and reports data for quality assessment/improvement activities. Maintains good rapport and open communication with CM staff, Medical Staff, internal and external customers.|Oversees that patients and their significant others understand medical recommendations through individual or group conferences. Supports patient rights and patient choice.

• Works collaboratively with LVN Case Manager, UR to complete TARs for assigned Medi-Cal patient population and obtains authorizations for managed care accounts and submits appeals for all denied cases. Oversees process and ensures that work is completed daily and in a timely manner. Demonstrates problem-solving, critical thinking, and prioritization of work to resolve issues as they arise. Maintains confidentiality of all information according to Hospital Policy and Procedure and legal and regulatory requirements.


• Reviews hospital admissions and continued stays in accordance with procedures, criteria, and standards approved by the medical staff. Identifies opportunities for improvement in the current processes and procedures. Escalates unresolved issues to direct supervisor or UM Facility Administrator per escalation process.


• Collaborates with Social Services, Clinical Team, patient and families to prepare patient's discharge planning needs. Oversees appropriate DC documentation. Works with Social Service to perform a variety of miscellaneous services, such as arranging for discharge or post-hospital plans, placement of patients in skilled nursing facilities or board and care homes.


• Collects and reports data for quality assessment/improvement activities. Maintains good rapport and open communication with CM staff, Medical Staff, internal and external customers.|Oversees that patients and their significant others understand medical recommendations through individual or group conferences. Supports patient rights and patient choice.