Imperial Management Administrators Services
Responsible for concurrent review and discharge planning for patients who are hospitalized. The review includes coordination of services for medical necessity, cost effectiveness, timelines of service and ensuring that quality standards are met. Performs coordination of services for patients whose health plan has an at-risk agreement to ensure that services are medically necessary, cost effective, provided in a timely manner and meet local standards or care. Familiar with MCG and Medicare guidelines.
ESSENTIAL JOB FUNCTIONS:
1. Research issues utilizing systems and clinical assessment skills, knowledge, and approved procedures in the decision-making process regarding health care services and care provided to members.
2. Requests and reviews medical records and notes as appropriate; evaluates for medical necessity and appropriate levels of care; collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Imperial Healthcare guidelines.
3. Perform concurrent review of hospitalized patients and formulates discharge plan/case management within two working days of admission.
4. Review referral requests for ambulatory patients for medical appropriateness based on health plan and other clinical guidelines adopted by the Imperial Healthcare guidelines.
5. Refer cases not meeting criteria for medical necessity to Medical Director during inpatient rounds.
6. Attend biweekly IDT CM meetings and other meetings as assigned.
7. Maintain records and statistics as required, i.e. – bed days, discharges, re-admissions, diagnoses.
8. Perform Discharge Planning/Case Management activities:
Implement discharge plan/case management and makes appropriate referrals to Home Health Agencies, Skilled Nursing Facilities, Board and Care Facilities, Hospice Care, etc. Works closely with the discharge planners at appropriate hospitals to facilitate timely transfer or discharge.
Arrange placement of patients in facilities that are appropriate for their level of care requirements.
Acquire authorization to Skilled Nursing Facilities, durable medical equipment, and home health care when medically necessary, included in the patients’ health plan benefits.
Maintain accurate and thorough documentation of discharge planning/case management activities on the patient’s medical records.
Identify and refer situations needing immediate intervention to Administrative Director of Managed Care, RN Manager, Medical Director, Quality Assurance and Risk Management, as appropriate.
· Graduate of an accredited school of nursing
· Minimum 1 year case manager experience
· Minimum 1 year managed care experience
· Hospital inpatient case management or ambulatory case management experience preferred
· Familiarity with Medi-Cal and Medicare guidelines
- Current California unrestricted LVN license
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