JOB SUMMARY: Coordinates interviews and reviews all medical records, as assigned to caseload. Actively participates in Case Management and Committee Team meetings. Responsible for reviewing patient medical information from medical records and various sources in order to assess, identify, plan, monitor, develop, and coordinate appropriate, cost effective care for all the PMG/IPA capitated members that present significant medical risks/liabilities, in the ambulatory and institutional settings. The scope of the program includes, but is not limited to: acute inpatients/ambulatory i.e. catastrophic cases, chronic cases, transplant/aids cases, institutionalized cases and any member requiring continuity and , ,coordination of care, transition of medical care from one setting to another, behavioral health care, or community resources. Able to work independently and use sound judgment. Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment. Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients and families, Interdisciplinary Care Team and all other committees as appropriate.
EDUCATION, EXPERIENCE, TRAINING
1. Knowledge of Utilization Management/Case Management terminology and functions, in both Managed Care and Non-Managed Care environments.
2. At least one year of experience as a Case Manager in an acute care setting or related field and coding chart review for meeting criteria purposes.
3. Basic to intermediate computer knowledge.
4. Must have a valid RN/LVN California License.
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