At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. MemorialCare stands for excellence in Healthcare. Across our family of medical centers and physician groups, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.
Essential Job Outcomes * Answer incoming calls from ED for authorization to admit. Determine if repatriation is appropriate per Healthplan contract. If patient is unstable for transfer, provide ED physician with contracted Hospitalist, Specialists and provide patients clinical history as needed. Transfer stable patient following established workflow and protocol. Document in EMR and notify PCP of patient admit. * Assist with direct transfer from ED to Skilled Nursing Facility if appropriate and ordered by ED physician. Follow established workflow and protocol. Notify PCP of patients admit. Assist with direct admit from PCP office to Hospital. * Support Inpatient Case Managers with chart review as delegated by the Healthplan. Document in electronic health record all clinical supportive of medical necessity, length of stay and level of care according to Milliman Care Guidelines. Adhere to turnaround times and bed day goals. * Demonstrate independent judgment, critical thinking and application of complex managed care regulations including but not limited to benefit structures, coverage, network contract, financial responsibility and care management. * Implement proper course of action and timely patient discharge in accordance with established protocols and guidelines in consultation with providers in all settings. * Evaluate and supervise a discharge plan for each member. Review and submit referrals per physician order and medical criteria such as durable medical equipment and home health, etc. * Evaluate risk for readmit and refer to Care Transitions, Complex, Disease Management, Collaborative Health Center (CHC) as warranted and within established time frames. * Make appointments for outpatient PCP follow up, Collaborative Health Center and Coumadin Clinic when requested. * Perform any additional/miscellaneous duties (not inclusive of job description) as requested by the management team within the scope of practice / licensure / knowledge/ability.
Experience * Minimum 5 years’ experience as a Registered Nurse with demonstrated competence in all aspects of nursing care and independent decision making. * Minimum two years’ experience in telephone triage. * Minimum three years’ experience care management or similar area. * Three years work experience in Microsoft Word, Microsoft Excel and Microsoft Outlook. * Three years work experience applying evidence-based criteria (i.e.: Milliman, Interqual); Health plan medical policy / clinical coverage guidelines. * Three years work experience with CMS (Centers for Medicare and Medicaid Services) coverage policies required. * Able to effectively and clearly communicate (written and verbal) in English. * Ability to work within approved procedure and clinical guidelines, tools and resources. * Ability to assess age specific groups from birth to geriatrics. * Excellent interpersonal communication (one-on-one, and group) and customer service and be able to work both independently and as part of a team. * Extremely organized self-motivated individual able to handle fluctuating volumes of work, able to prioritize work to meet deadlines. This includes estimation of effort, time management and developing realistic timelines for projects and tasks. * Ability to independently make and document sound judgments in emergency situations while demonstrating initiative and responsibility. * Ability to effectively communication with all stakeholders. This includes the ability to professionally and diplomatically debate difficult topics while supporting the Company's position. * Enhances own professional growth and development through participation in education programs, current literature, in-services, meetings and workshops.
MemorialCare Medical Group is a physician-based organization established to provide advanced comprehensive, effective and efficient health care. With over 30 locations from Long Beach to Dana Point, MemorialCare Medical Group includes more than 250 physicians in the areas of internal medicine, family medicine, pediatrics, geriatric medicine, cardiology, cardio thoracic surgery, gastroenterology, neurology, pulmonology, psychiatry, psychology, rheumatology, sleep medicine and therapeutic acupuncture. In addition to multiple locations throughout Orange County, MemorialCare Medical Group offers Urgent Care Centers that are open 365 days-a-year, Telephone Advice Nurses available 24 hours-a-day, 7 days-a-week; and lab and digital X-ray services available on-site at most locations.