(This list may not include all of the duties assigned.)
1. Analyze and evaluate medical records and other health data to meet medical necessity determination based on the criteria for In patients and Emergency Room patients at Santa Barbara Cottage Hospital and Santa Barbara Cottage Rehabilitation.
2. Promote a collaborative relationship with the medical staff, especially Hospitalists.
3. Support services to reduce bed days and provide quality patient care across the continuum of care.
4. Monitor and assist in the coordination of a comprehensive plan of care and discharge plan.
5. Maintain effective communication with Health Plan Case Managers and work collaborately.
6. Assist in the development of Ambulatory Case Management strategies to support members with chronic conditions to improve healthcare outcomes.
7. Prepare and maintain internal files and logs for members served by Case Management program and methods of tracking activities.
8. Participate in Case conference with Hospitalists.
9. Coordinate with contracted vendors, hospital Case Managers, and providers.
10. Refer cases to Assistant Medical Director as needed
11. Call in reviews to Health Plans as requested.
12. Facilitate quality of care and service by referring any potential quality issue.
13. Identify under/over utilization issues and refer to Patient Care Committee.
14. Handle High Cost injectable drugs based on Sansum Clinic injectable process.
15. Coordinate all aspects of patient care involving transplant and high risk/high cost acute and chronic ambulatory management.
16. Perform other related duties as needed.
17. Maintain strictest confidentiality in accordance with Sansum Clinic policy.
40 Hours Per Week
Graduate of an accredited school of nursing, and hold a current California RN license. Five (5) years Case Management, Utilization Management experience. Minimum of two (2) years experience in ambulatory, acute care nursing, with a thorough familiarity of health plan, managed care, and customer service.