Description: Job Summary:

The LVN/LPN Case Manager Assistant is responsible to conduct medical necessity screening and work collaboratively with the interdisciplinary team to provide care coordination for patients under the direction of a Registered Nurse and in compliance with evidence-based practice and regulatory requirements. This position complies with the scope of services defined by the Licensed Vocational /Practical Nurse LVN/LPN state licensure requirements. This position integrates national standards for case management scope of services including: Utilization Management supporting medical necessity and denial prevention, Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care, Compliance with state and federal regulatory requirements, TJC accreditation standards and policy Education provided to physicians, patients, families and caregivers, and other duties assigned.

Essential Responsibilities:

The individuals responsibilities include the following activities:

a) accurate medical necessity screening and submission for Physician Advisor review
b) care coordination,
c) implementation of the transition plan based on RN Case Manager and/or Social Worker (SW) assessment(s), 
d) communication with interdisciplinary team during patient care conferences, e) management of concurrent disputes,
f) communication with patients and families regarding the plan of care established by RN, SW and Physician, 
g) collaboration with physicians, office staff and ancillary departments,
h) clear, complete and concise documentation in electronic system, 
i) maintenance of accurate patient demographic and insurance information, 
j) identification and documentation of potentially avoidable days, 
k) identification and reporting of over and underutilization, 
l) and other duties as assigned


Utilization Management:

Assures the patient is in the appropriate status and level of care based on Medical Necessity process and submits for Secondary Physician review per Kaiser policy
Ensures timely communication of clinical data to various payers to support admission, level of care, length of stay and authorization for post-acute services
Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
Completion of clinical reviews
Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
Identifies and documents Avoidable Days using the data to address opportunities for improvement
Prevents denials and disputes by communicating with payers and documenting relevant information
Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) supported by evidence-based practice, internal and external requirements.
Identifying appropriate level of care needs
Assisting with patient transition to the appropriate level of care
Order clarification admission status and patient classification.
Maintain and foster timely and accurate with all members if the multidisciplinary team.
Escalates barriers to patient care as appropriate
Other duties assigned.
(30% daily, essential).


Transition Management:

Makes referrals for post-acute services based on  needs identified by the RN Case Manager or SW staff assessment and utilizing the electronic Case Management system
Provides patients and families with choices of post-acute providers per Kaiser policy.
Based on SW and RN assessment and plan follows up on readmitted patients and implement strategies to address opportunities outlined.
Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers.
Identifies and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes documentation in the Case Management system to communicating information through clear, complete and concise documentation
(30%daily, essential)


Care Coordination:

Follows up on patients identified by the SW and /or RN Case Manager on factors that may affect the progression of care
Ensures consults, testing and procedures are sequenced to support the patients clinical needs with timely and efficient care delivery
Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical and transition outcomes.
(15% daily, essential).


Education:

Contributes to the education to patients  and the care team relevant to the
Effective progression of care,
Appropriate level of care, and
Safe and timely patient transition
Provides patients and healthcare team information regarding resources and benefits available to the patient along with the economic impact of care options
Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge
(15% daily, essential).


Compliance:

Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Kaiser policies.
Operates within the LVN/LPN scope of practice as defined by state licensing regulations
Remains current with Kaiser Utilization Management/Case Management practices
(10% daily, essential)


PRIMARY INFORMATION, TOOLS AND SYSTEMS USED:

Patient data - hospital admission, discharge, transfer system
Healthcare staff documentation related to patient care
Regulatory and payor requirements
Kaiser Plan benefits
Health Connect
Tapestry
McKesson Care Enhance Review Manager (CERMe) InterQual system
Clinical data interface and secure faxing
Patient Medical Record including Health Connect and Tapestry
Hospital specific Clinical Software


PERFORMANCE METRICS AND EVALUATION:

The metrics below provide an indication of the effectiveness of the individual in this role and may be used for evaluative purposes. The list below is not meant to be exhaustive; other relevant metrics may exist.
InterQual reviews
Observation hours
Excess Days/ALOS
Patient Day Rate
IQM metrics
Number and type of avoidable days
Resource Utilization


SUPERVISORY RESPONSIBILITIES:

None


Basic Qualifications:
Experience

Minimum two (2) years of hospital or ambulatory or post-acute experience.

Education

High School Diploma or General Education Development (GED) required.

License, Certification, Registration

Vocational Nurse License (California) OR Licensed Practical Nurse (in the state where care is provided)


Additional Requirements:

Skills required include excellent organizational skills, excellent verbal and written communication skills, demonstrated problem solving skills, and computer literacy.
Must complete InterQual test and pass with a score of 85 or better within 60 days of hire and annually.
Must complete and demonstrate competency in using the Kaiser/Utilization Management/Case Management documentation system within 60 days of hire.
Attendance at hospital and department orientation is required.
Department orientation includes review and instruction regarding Utilization Management/Case Management, Compliance policies, InterQual, Transition Management, and other topics specific to case management.


Preferred Qualifications:

Hospital Case Management experience preferred.

Notes:

• Rotating weekend and holidays.