Case Manager II - Utilization Management

At Lucile Packard Children’s Hospital Stanford, 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.

Job ID: P140091-2660347

JOB SUMMARY

This paragraph summarizes the general nature, level and purpose of the job.

Case Managers are licensed nursing professionals responsible for coordinating continuum of care and discharge planning activities for a caseload of assigned patients. 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. 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. 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.

ESSENTIAL FUNCTIONS

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 hospital's policies and procedures, including its Service Standards and its Code of Conduct.

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.

DISCHARGE PLANNING

* 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.

EDUCATION/CONSULTATION

* 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.

LEAD WORK

* May lead the work of administrative/clinical support staff responsible for assisting with case management for an assigned patient caseload.

OTHER

* 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.

QUALITY IMPROVEMENT

* 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.

THIRD-PARTY REIMBURSEMENT

* 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.

UTILIZATION REVIEW

* 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.

MINIMUM QUALIFICATIONS

Education: Bachelor's Degree in Nursing from an accredited college or university

Experience: Two (2) years of progressively responsible and directly related work experience

License/Certification:

• Registered Nurse by California Board of Registered Nursing
• Basic Life Support by American Heart Association (AHA) or RQI Healthcare Provider Basic Life Support

KNOWLEDGE

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

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.

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Pay Range
Compensation is based on the level and requirements of the role.
Salary within our ranges may also be determined by your education, experience, knowledge, skills, location, and abilities, as required by the role, as well as internal equity and alignment with market data.
Typically, new team members join at the minimum to mid salary range.
Minimum to Midpoint Range (Hourly): $111.35 to $126.14

Stanford Medicine Children's Health (SMCH) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SMCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance.