Case Manager, (Rn) - Utilization & Denial Appeals Management - Full-Time (1.0 Fte) 8 Hr. Days (Remote)

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Day - 08 Hour (United States of America)

Why work at Stanford Medicine | Stanford Health Care (SHC)?
Whether this would be your first case management role, or you are seasoned, here is your opportunity to work with a unique and supportive team. You can put your bedside RN experience to great use in case management.
Our RN Case Managers work with multidisciplinary teams.
Become part of a team that has been able to influence and direct the continuity of patient care.
This is a remote (work-from-home) role.
This is not a CRONA-union position.

This is a remote (work-from-home) Stanford Health Care 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.
Locations
Stanford Health Care (remote)
What you will do

• 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.
• 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.
• Third-Party Reimbursement - Collects, analyzes reports and reviews patient information with third-party payers to assure reimbursement for patient services/procedures. Communicates with review organizations / payers to provide requested clinical and psychosocial information to assure reimbursement.
• 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.
• 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.
• 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.
• 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.

Education Qualifications

• Bachelor's degree in Nursing (BSN) from an accredited college or university

Experience Qualifications

• Three (3) years of progressively responsible and directly related work experience preferred

Required Knowledge, Skills and Abilities

• Knowledge of the models of case management, including the principles and practices of discharge planning, utilization review, and quality assurance / improvement
• 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 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
• 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
• Knowledge of available patient services and treatment
• Ability to understand, interpret and apply complex federal and state hospital compliance laws, rules, regulations, and guidelines
• Knowledge of the variables that affect the processes and outcomes of patient health care
• Ability to resolve conflicts and/or negotiate with others to achieve positive results; establish and maintain effective interpersonal relationships
• Ability to develop and perform patient assessment and plan of care
• Ability to collect and record data, evaluate data and statistics, and maintain effective reporting systems
• Knowledge of the full continuum of care available to patients, interrelationships of the care components, and their effective integration
• Knowledge of financial processes of various private and public funding sources for health care services/procedures
• 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 remain knowledgeable regarding available treatments and services
• Knowledge of evaluation and assessment techniques
• Ability to work effectively with individuals at all levels of the organization

Licenses and Certifications

• Nursing / RN - Registered Nurse - State Licensure and/or Compact State Licensure required

These principles apply to ALL employees:
SHC Commitment to Providing an Exceptional Patient & Family Experience
Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.
You will do this by executing against our three experience pillars, from the patient and family’s perspective:

• Coordinate for Me: Own the complexity of my care through coordination
• Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
• Know Me: Anticipate my needs and status to deliver effective care

Equal Opportunity Employer Stanford Health Care (SHC) 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, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, 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.

Base Pay Scale: Generally starting at $68.38 - $90.62 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.