Medical Claims Review Manager jobs in Santa Ana, CA

Updated: Apr 5, 2024
Location: Fountain Valley
Job Type:
Department: Utilization Review-FVR

Position Title: Case Manager

Case Manager Job Code: R5001 HR Approval: Date:

Reports to: Director of Case Management

Position Summary:

The Case Manager accomplishes patients’ care by assessing treatment needs developing, monitoring, and evaluating treatment plans and progress; facilitating interdisciplinary approaches, coordinating and providing care that is safe, timely, effective, efficient, and patient-centered.

Essential Duties:

• Assesses admission necessity utilizing the IQ SI/IS criteria for fee-for-service Medicare patients, all other payers will be handled by Tenet Call Center (TCC). Review date will be assigned. If treatment plan does not meet criteria, the UR nurse will refer case to attending physician. If no determination, the UR nurse will refer the case to the UR Physician Advisor.
• Performs the initial IQ and clinical review within one working day of admission and documents in Allscripts all that are not reviewed by TCC within 24 hours.
• Performs continued stay IQ and documents in Allscripts a concurrent review every 3 days or sooner, depending upon the payer, change in LOC, or clinical status.
• Reviews all Observation patients daily and performs inpatient IQ.
• Initiates discharge planning per Department standard. All payer sources are screened for high risk, high volume and problem prone patients.
• Conducts Adult Transition Evaluations with patients and significant others within 24 hours of admission. Explores avenues of discharge planning.
• Demonstrates a knowledge of human behavior and counseling skills as they relate to patient and staff needs
• Documents in Allscripts information and events as they occur. Maintain verbal and written communication with physician, staff, and family regarding discharge planning process. Notes signed (with name and title) and dated with each entry into the discharge planning record.
• Implements innovative discharge planning when needs are out of the ordinary or resources unavailable. Utilizes insurance plan's case management for planning, if available.
• Assists patients and families with information regarding social, economic and emotional aspects and makes necessary referral to social work, financial counseling or educational resources. Acts as a resource to patients and families.
• Assists physicians in transferring patients to other facilities. Coordinates exchange of information, records, transportation and notifications. Documents activities in Discharge Planning notes.
• Educates medical and nursing staff on discharge planning for continuity of care. Lower level of care; i.e., role of HHC, SNF, REHAB, etc. Interprets, CCS Medi-care, Medi-Cal, IMS, private insurance and HMO's as they pertain to discharge planning.
• Acts as a community relations person. Participates in meetings and in-services by outside providers. Networks with others in the community.
• Participates in and initiates family conferences as needed and weekly complex case reviews.
• Returns all telephone reviews to insurance companies within one working day.
• Updates Discharge Plan and barriers on the eTEMPO board daily.
• Actively participates in daily TEMPO rounding.
• Transfer Center duties
• Completes other duties as assigned.

Specific to the Resource Case Manager:

• Must be willing to train and educate new Case Managers and Discharge Planners.
• Must be willing to Mentor new Case Managers.
• Must be flexible in work assignments with floating to units as needed.
• Must be willing to assist other Case Managers with clinical reviews, ATEs, two-midnight forms, and other duties as assigned.
• A self-starter and willingness to make Case Management a career.

Education and

Experience Required: ·

Minimum Education:

Current California RN license ·

Minimum Experience:

Three to five years of experience in an acute care hospital setting (medical/surgical preferred) · Must be proficient in typing. · Ability to write and communicate professionally · Must be proficient in computer skills including Microsoft Office Preferred: · Broad knowledge of Medicare, Medi-Cal and insurance guidelines. · Critical care experience (For Resource Case Manager)

Requirements Hospital Mandatory Education Requirements: Orientation, Environment of Care, OSHA, Infection control, Abuse/Neglect, Ethics, etc. Tuberculosis Screening Fit Mask Testing Licensure Renewal ACLS PALS NRP BLS CPI End of Life Education Physician On-Call Roster Education Moderate Sedation Education/Competency Waived Testing Education/Competency Clinical Practice Guidelines/Clinical Protocols Education Other (describe): Annual InterQual training, Compass training, and other mandatory hospital education