Registered Nurse (RN) - Case Management
Kindred Hospital Rancho
Rancho Cucamonga, CA

ScionHealth is committed to a culture of service excellence as demonstrated by our employees’ adherence to the service excellence principles of Pride, Teamwork, Compassion, Integrity, Respect, Fun, Professionalism, and Responsibility.

As our most acute level of care, our specialty hospitals offer the same critical care patients receive in a traditional hospital or intensive care unit, but for an extended recovery period. Our clinicians play a vital role in the recovery process for chronic, critically ill and medically complex patients.

Job Summary

Under the supervision of the Director of Case Management (DCM) or designee, completes various duties to enhance the efficiency of the Case Management Department, as well as support the daily functions of the Case Managers. This role assists in securing arrangements for the discharge transition and post-acute services. Works with the Case Management team to monitor and obtain insurance verifications and concurrent authorizations. Assists with denial prevention and management as requested, aiding with the peer-to-peer coordination, and denials / appeals tracking. This position serves as a liaison between the Case Management department, payers, post-acute providers and various other entities.

Essential Functions

• Provides assistance to the Case Management staff, including, but not limited to; creating and sending referral packets, organizing admission and discharge patient records, making phone calls, obtaining signatures, or any other assistance needed as determined by the DCM.
• Assists the Case Management team in scheduling family conferences.
• Assists the Case Management team by making necessary arrangement for post-discharge follow-up care.
• Functions as the point of contract and liaison for the hospital Case Management department staff regarding clinical insurance review completion and/or issues.
• Forwards the necessary patient clinical information for all admission, concurrent, and retrospective insurance reviews to payers for the completion of medical necessity reviews.
• Monitors, follows-up, documents and tracks payer responses / requests of completed clinical reviews, including; approvals, appeals and denials and communicates these to the appropriate people (hospital staff, physicians, DCM, Case Manager(s), Clinical Denial Management, and Centralized Business Office {CBO}).
• Monitors and tracks the total hospital certified days of the patient for payers (commercial, managed care, and Medicaid) and communicates missing certifications to the DCM, Case Manager(s), and CBO.
• Initiates and completes insurance pre-certification for patients lacking certification. Communicates pre-authorization outcomes to appropriate individuals (hospital and CBO).
• Organizes and prepares the necessary clerical elements for the weekly Interdisciplinary Team Meeting and other Case Management meetings.

Knowledge/Skills/Abilities/Expectations

• Must read, write and speak fluent English.
• Must have good and regular attendance.
• Ability to learn logistics of insurance verification and certification process, case management and discharge planning tasks.
• Clinical knowledge to read, interpret, and communicate information in the medical record that identifies diagnoses, treatment plans, interventions and medical necessity for hospitalization.
• Knowledge of Medicare benefits and insurance processes and contracts.
• Knowledge of accreditation standards and compliance requirements.
• Excellent interpersonal, verbal and written skills in order to communicate effectively and to obtain cooperation / collaboration from hospital leadership, as well as physicians, payers and other external customers.
• Ability to work under stress, multitask, and to respond quickly in urgent situations.
• Performs other related duties as assigned.
• Approximate percent of time required to travel: 0%

Education

• College degree in a healthcare related field preferred

Licenses/Certification

• None required.

Experience

• 1 year in a healthcare setting.