Registered Nurse Case Manager - Case Management - Full Time/Days in Lancaster, CA at Antelope Valley Hospital

Date Posted: 7/27/2020

Job Snapshot

  • Employee Type:
  • Location:
    Lancaster, CA
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:

Job Description

Under the direction of the Director of Case Management, or designee, the Register Nurse (RN) Case Manager is responsible for prioritizing, planning, and monitoring the patient's progress through the Antelope Valley Hospital system. The Case Manager assesses for appropriate medical care with effective utilization of resources while promoting continuity of care. The RN Case Manager provides guidance and oversight to the LVN Discharge Coordinator, the Discharge Coordinator Assistant and the Utilization Review Assistant.

Essential Duties and Responsibilities:

A. Case Management

  1. Identifies care not meeting acute care criteria, or care that could be provided at an alternate level of care and researches, communicates and recommends alternative cost effective health care services to the health care team
  2. Maintains knowledge and understanding of Medicare, Medi-Cal, CCS, GHPP, Managed Care, and other payer regulations and benefit limits
  3. Acts as a resource to physicians and nursing staff regarding discharge planning and all issues that may affect resource utilization and reimbursement
  4. Facilitates transitions of patients to the most appropriate level of care by providing pertinent clinical information to other health care providers
  5. Works with onsite reviewers to facilitate communication of authorizations and documentation of discharge plans provided by the onsite reviewer
  6. Utilizes the HDM and LING systems to trigger and monitor discharge planning and social work needs
  7. Serves as a hospital and patient advocate regarding all clinical, social, financial and ethical healthcare matters
  8. Identifies and reports abuse of children and adults as mandated by state law
  9. Performs other duties as assigned

B. Utilization Review (UR) Management

  1. Accurately completes admission, concurrent and retrospective reviews of the medical record in the HDM system for Medicare, Medi-Cal and other payers utilizing InterQual criteria for Severity of Illness and Intensity of Service criteria
  2. Evaluates the medical record for documentation that supports services provided
  3. Notifies the physician if documentation does not support the level of care provided and actively works with physicians on the concurrent medical record to improve accuracy and efficiency in capturing pertinent documentation
  4. Utilizes the PCC Physician Advisor as needed for intervention with the medical staff relative to medical necessity, utilization of services, clinical documentation, denial review or clarification of discharge plan
  5. Monitors payer authorizations to provide timely concurrent reviews and provides payers with pertinent clinical information for authorization and reimbursement of care
  6. Completes appropriate documentation as required by payors, including but not limited to TARs and CCS referrals
  7. Monitors and develops action plans for metrics including length of stay and resource utilization uses data to identify trends and problem utilization areas including avoidable days
  1. uses data to identify trends and problem utilization areas including avoidable days
  2. Identifies drivers of variation of care for high cost, high volume DRGs to assist in focused DRG effort
  3. Notifies the physician of potential or actual concurrent denials. Intervenes with the physician, the Physician Advisor and the payer to attempt resolution of denial issues. Consults with the Physician Advisor and department Director and issues letters of non-coverage when appropriate
  4. Reviews denied claims to evaluate for potential appeal. If appropriate, prepares appeal including documentation to support care provided and coordinates with the Utilization Review Assistant to assure timely submission of the appeal
  5. Provides physician education regarding denied claims to minimize future denials
  6. Refers to the Discharge Coordinator or Social Worker when indicated to facilitate the patient's transition to the appropriate level of care

C. Discharge Planning

  1. Responsible for the timely development, implementation and documentation of an individualized discharge plan in collaboration with the patient, their family and the physician
  2. Based on patient needs, updates the Discharge Plan throughout the hospital stay and maintains accurate, timely documentation on the medical record to enable other members of the Healthcare Team to complete the plan
  3. Communicates the Discharge Plan to the health care team
  4. Facilitates use of the most appropriate level of care to conserve patient, hospital and payer resources
  5. Obtains authorizations for discharge planning needs, and if necessary, negotiates with payer to maximize post acute care benefits
  6. Works with the Discharge Coordinator Assistant to facilitate placement and transfers to other acute and post acute care facilities
  7. Works with the Discharge Coordinator Assistant and the nursing unit staff to coordinate medical transportation
  8. Assesses for Home Health, Home Infusion and DME needs, makes referrals to the appropriate agencies and documents in the medical record to facilitate the completion of arrangements
  9. Develops and maintains knowledge and understanding of hospital and community resources
  10. Provides patients with referrals to and education of community resources
  11. Collects and uses data to identify trends and utilization of discharge planning resources

Non-Essential Duties:

  • Assist with other duties as assigned, within skill sets and abilities


  • InterQual Guidelines
  • Working knowledge of Government, State, HMO, PPO, Commercial, and Workers Compensation utilization, authorization and billing guidelines
  • Working knowledge of Microsoft Office applications
  • Working knowledge of medical terminology


  • Knowledge of basic personal computers
  • Proficient in the operation of scanners, copiers, and fax machines
  • Good oral and written communication skills
  • Good interpersonal skills and customer focus


  • Ability to handle stress
  • Ability to manage a heavy caseload in an organized and efficient manner
  • Ability to maintain a working relationship with other facilities and departments within the organization
  • Ability to document account information at time of account follow-up
  • Ability to run case management related reports as needed

Core Competencies: All AVH employees will effectively demonstrate these behaviors:


Action Oriented

Customer Focused


Effective Communication


Ethics & Values

Integrity & Trust

Education and Experience:  Education

  • High School graduate or equivalent
  • Bachelor's Degree in Nursing, preferred


  • Minimum 3-years broad-based acute care nursing experience
  • Case Management, Discharge Planning, and/or Home Health experience, preferred

Required Licensure and/or Certifications:

  • Registered Nurse License
  • CPR certification

Key Physical Requirements and Working Conditions:

  • Primarily works in a climate-controlled area
  • Standing and/or walking 75% of time on duty
  • Tolerate repetitive arm and hand movements

A detailed description of the physical requirements of this job is maintained in the Employee Health Department.


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