RN Case Manager Case Management in East Los Angeles, CA at East Los Angeles Doctors Hospital

Date Posted: 1/1/2022

Job Snapshot

Job Description

Job Title: RN Case Manager – Case Management

Job Summary:

  • Performs a wide variety of tasks and functions including utilization review, discharge planning, and care coordination to assure the delivery of necessary services, efficient patient progression, and payment for the services provided.
  • Serves as a liaison between the designated Avanti Hospital and payers to ensure financial coverage for the patients on a concurrent basis and documents supporting activities.
  • Collaborates to coordinate resources and services for the patient/family in response to individual needs and fiscal responsibilities.
  • Works with the clinical multidisciplinary team to ensure coordination of patient care and wise utilization of resources to include appropriate level of care based on InterQual criteria, and communication with the health plans. 
  • Documents case management activities in the patient record and in the required information system i.e. in Paragon UR Program, CERME, Nursing Progress Notes.
  • Works varying shifts including regular evenings and weekends. 

Essential Job Duties: 

  • Applies appropriate clinical knowledge in order to identify patient needs and effectively communicate medical necessity and treatment plan to payers.
  • Concurrently and retrospectively reviews all inpatients and observation patients based on the Paragon UR work queue, the Avanti census and electronic health plan reports for appropriateness of admission, level of care, and length of stay utilizing InterQual criteria and documents in Paragon UR Program.
  • Attends rounds with the Physician Advisor, nursing and other members of the Case Management team to discuss the gaps in patient care, respond to the patients’ needs, identify the plan of care and advise of potential discharge needs.
  • Reviews and works incoming denials received via fax or through correspondence (in-house patients).  If the patients are discharged, scan, document and forward the denial letters to the Central Business Office (CBO).
  • May assist with ED Admissions to determine the appropriate level of care and discuss with ED and Admitting physicians and health plans.
  • Submits daily clinicals and confirms the payor receipt and authorization status during the patient’s hospital stay, per the plan contract (but no less frequently than every 3 days).
  • Educates and collaborates with the multidisciplinary team including physicians, nurses, social workers, physical therapy, dietary etc. and patients/families regarding utilization issues and medical necessity to provide choices for discharge options and community resources post-acute care stay.
  • Documents options and discharge plans in CERME, Paragon UR, eRecord and other Avanti Systems.
  • Estimates the expected length of stay (ELOS) based on the knowledge of the patient’s condition and barriers to discharge and interactions with the interdisciplinary team. Communicates expected discharges to the unit charge nurse, patient unit and family.
  • Identifies patients at risk for extended lengths of stay, readmission, and complex discharge needs, documents in Progress Notes and Paragon UR, completes Complex Case Log and submits to CM Director, Administration and the CBO.
  • Identifies and documents Avoidable Days using evidence based data to address opportunities for improvement.
  • Prevents denials and disputes by communicating with payers daily and documenting relevant information in Paragon UR.
  • Reviews and works incoming denials or denied days received during follow up calls, fax or correspondence (in-house patients).  If patients are discharged, scans, documents and forward letters to the CBO.
  • Works Claims Retention Criteria (CRC) Report to ensure that edits are cleared for timely billing.
  • Completes Medicare Outpatient Observation Notice (MOON) letters and gives and explains the Important Message from Medicare (IMM) letters 48 hours before discharge to the patient and/or family members.
  • Provides/submits payor notifications of discharge, transfer or death and confirm all days have been authorized. If any days are not authorized, notify the Director stating why and start the first level appeal process.
  • Transmits care summary to next level of care if other than home.

Job Requirements


  • Bachelor’s degree in Nursing preferred, Master prepared a plus.
  • Minimum of 2-3 years in Case Management Acute Care setting.
  • Knowledge of healthcare reimbursement systems: HMO, PPO, capitated agreements, and PPS.
  • Advanced knowledge of post- acute healthcare resources such as SNF, Home Health and Hospice.
  • Strong clinical assessment skills necessary to provide utilization review and transition planning services to meet the patients’ complex medical, emotional and social needs.


  • Current RN licensed in good standing by the California Board of NursingCurrent BLS for Health Care Provider card.
  • Accredited Case Manager (ACM) or Certified Case Manager (CCM) a plus.