Case Management/Utilization Review LVN, Behavioral Health in Norwalk, CA at Pipeline Health

Date Posted: 12/3/2022

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    Norwalk, CA
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
    12/3/2022

Job Description

Each day is a fresh opportunity to impact the lives of our patients, families, co-workers, and communities. We promote excellence, optimism, respect, and professional growth. If you are looking for a rewarding and positive workplace, look no further than in your own community! 

Summary:

This position supports the Mission of the Hospital through the provision of distinctive and compassionate care to our patients. This position is responsible for utilization review, assessment of discharge planning needs and coordination of effective discharge plan.

Responsibilities:

  • Demonstrates effective clinical skills in assessment of medical necessity for observation and inpatient encounters
  • Performs Initial UR within first business day of encounter and concurrent reviews to assess for medical necessity for hospitalization and continued stay utilizing InterQual Criteria (IC). Refers cases not meeting IC for observation. Inpatient encounter or continued stay to the Physician Advisor (PA) for review. Documents initial and concurrent reviews on review worksheets for Medicare, HMO/PPO and self-pay cases and on TARS for Medical cases.
  • Provides Initial and concurrent reviews to health plans or designated IPA (written or verbal as requested by health plan/IPA). Documents authorization or denial provided by health plan or IPA for hospital encounter in Cerner APPS. Notifies attending physician immediately if acute care encounter is denied.
  • Informs attending physician of any limitations of health insurance benefit coverage for hospital care (i.e. emergent care codes for Medical benefits, any exhausted benefit issues, lack of medical insurance) and facilitates notification of financial counselor for their follow up.
  • Identifies charts that have insufficient documentation, treatment plan and/or medical necessity to justify admission or continued stay and communicates with attending physician and/or consultant.
  • Demonstrates effective clinical skills in assessment of discharge planning needs and coordination of appropriate discharge plan
  • Assesses discharge planning needs with initial review in collaboration with patients, their family or support systems, physicians and other multidisciplinary team members and coordinates patient’s discharge planning needs.
  • Identify patients at risk for re-admissions and establish effective discharge plan that includes coordination of community resources such as In-Home Supportive services (IHSS), meals on wheels, community van transportation services, referrals to area/county clinics and scheduling follow-up appointments with primary care physicians as indicated.
  • As part of coordination of discharge planning needs, facilitates referrals to other acute care, long term care facilities, community resources, home health agencies (HHA) and durable medical equipment (DME) vendors with appropriate documentation entered in electronic medical record (EMR). Utilizes contracted acute care facilities, skilled nursing facilities (SNF), HHA”S and DME vendors as required by delegated health plan or IPA.
  • Provides patients/families written resource information on Medicare Certified SNF’s and HHA’s when the plan is for SNF placement or home with home health. Works closely with the patient and family to coordinate referral to facility or agency of patient’s preferred choice.
  • Contacts Social Worker at time of initial and/or concurrent review when concerns identified regarding patient’s psychosocial or community resource linkage needs, financial issues that could impact continuum of care on discharge, or identified reportable adult/elder/child abuse.
  • Actively participate in multidisciplinary team rounds and collaborate with other disciplines to affect an appropriate discharge plan.
  • Demonstrates effective clinical assessment skills to identify any quality of care issues and to report to Quality Management
  • Identifies any delays in services ordered by physician and communicates with appropriate departments or providers to help ensure patient receives services ordered timely at that point.
  • Identifies any quality of care concerns including but not limited to post-surgical complications.
  • Generates Notification/Occurrence Reporting Form and provides to Manager of Case Management for review and signature. Send completed Notification/Occurrence Reporting Form to Quality Management Department.
  • Demonstrates ability to provide education to healthcare providers regarding role of Case Management
  • Identifies education needs and provides instruction on identified needs in an effective manner.
  • Participate in new employee orientation as requested.
  • Educates hospital staff, physicians, and house staff in the Case Management process.
  • Demonstrates dedication to meeting the expectations of external costumers
  • Acts appropriately as a liaison between QIO and this hospital in preparing charts for any QIO audit as requested.
  • Maintains working relationship with all outside review organization.
  • Maintains and utilizes a Community Resource Book for discharge planning which includes facilities, outreach programs, and special interest for our patients.
  • Maintains Necessary licensing, certification and knowledge while attending all required classes

QUALIFICATIONS

  • Current CA Nursing License LVN
  • Current CPR BLS for healthcare provider’s card upon hire
  • Two years previous clinical experience in acute care setting. Minimum one year experience as case manager in acute care setting.
  • Demonstrate the knowledge and skills necessary in Case Management with an understanding of severity of illness and intensity service.
  • Ability to demonstrate knowledge and skills necessary to provide care appropriate to the age served on the unit. Possess knowledge of growth and development over the life span.

ADA CONSIDERATION: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant in order to be considered.

LANGUAGE SKILLS: Must be able to read, analyze, and interpret common scientific and technical information, and to be easily understood through verbal communication in the English language. Must be able to prepare documentation in a manner that conforms to prescribed style and format, and to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Bilingual skills (Spanish) preferred.

MATHEMATICAL SKILLS: Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to perform these operations using units of weight measurement, volume, and distance. Ability to perform upper level mathematical operations, including algebra and geometry, frequent distribution, determination of test reliability and validity, analysis of variance, correlation techniques, sampling theory and factor analysis.

PHYSICAL DEMANDS: Is occasionally required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl; talk or hear; and taste or smell. The employee is regularly required to lift, push and/or pull weights in excess of 10 pounds. The employee must occasionally lift and/or move more than 100 pounds, with assistance. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

WORK ENVIRONMENT: Is occasionally exposed to toxic or caustic chemicals, risk of electrical shock, and vibration.