Clinical Integration Manager Jobs in California (NOW HIRING)

Shift: 7:00am - 7:30pm

Patient Population: The patient population served can be all patients, including geriatric, adult, adolescent, pediatric, and newborn. This also includes services which affect facility staff, physicians, visitors, vendors and the general public.

Position Summary: Under the direction of the Care Integration Manager (LCSW) and clinical oversight by the Vice President of Quality and Regulatory Affairs (LCSW). The ED Care Coordinator uses pre-established guidelines and criteria to perform review activities assuring proper utilization of hospital resources for Medicare, Medi-Cal, HMO's and other third party payers. Takes appropriate follow up action when established criteria for utilization of services are not met, in order to assure that denials are avoided. Identifies medically indigent patients and monitors closely to ensure that appropriate placement is secured; works with patient and family to determine if other sources of funding may be applicable. Maintains appropriate documentation of review performed, according to pre-established criteria, indicating severity of illness and intensity of services rendered with acute/ post-acute hospitalization. Acts as Liaison with physician(s) to: ( 1) ensure all covered aspects of treatment are fully documented, and (2) assists in identifying other options for care when patient no longer requires acute hospitalization, securing appropriate discharge planning and home health services, and long-term care placement. Must be able to work normal/scheduled working hours to include Holidays, call-backs, weeknights, weekends, and on-call. Agrees to participate, as directed, in emergencies and community disasters during scheduled and unscheduled hours. As a designated disaster service worker you are required to assist in times of need pursuant to the California Emergency Services Act. (Gov't. Code §§ 3100, 3102) Needs to recognize that they have an affirmative duty and responsibility for reporting perceived misconduct, including actual or potential violations of laws, regulations, policies, procedures, or this organization's standards/code of conduct. The employee shall work well under pressure, meet multiple and sometimes competing deadlines; and the incumbent shall at all times demonstrate cooperative behavior with colleagues and supervisors.

Education/Training/Experience: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

In order to qualify for this position, candidates must meet one of the following 2 criteria: 1. An individual must have a master's in social work OR a master's in a healthcare related field. 2. One year of experience performing social services casework services in an acute care setting and will obtain Master's degree in social work or healthcare related field within 90 days from the date of employment.

One year or more experience in an Acute Care setting preferred. Prefer one year's experience with discharge planning.

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence if required. Skills in written and oral formats of communication.

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages if required.

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

To perform this job successfully, an individual should have good computer skills, such as Windows.

Licensure/Certifications: Certification in Case Management desirable. LCSW license is preferred. Must have and maintain current BLS certification or obtain within orientation process, prior to hands-on patient care. Must have and maintain Associate Clinical Social Worker (ACSW) or Associate Marriage & Family Therapist (AMFT) certification within 90 days of hire or transfer. Tulare County Law and Ethics- Involuntary Treatment and the 5150 training/test to be completed within 90 days of hire date.

Responsibilities and Essential Functions:

• Utilizes InterQual/MCG criteria for medical necessity and appropriateness of admission/continued stay or assignment to observation status. Takes appropriate action if patient does not meet criteria.
• Acts as a resource to other departments in developing greater awareness of InterQual/MCG criteria and to interpret requirements of Federal, State, and third party payor guidelines for coverage.
• Ensures that all affected hospital departments receive timely notification of inappropriate admission, and provides administrative determination documentation.
• Communicates with the patient/family and physicians regarding issues related to financial coverage which may negatively influence post Acute Care plan, including discussing alternatives and options as available and appropriate.
• Demonstrates ability to transmit referral electronically or by phone referral to physician advisor in a timely manner in cases of potential denial of medical necessity for admission or continued stay.
• Demonstrates ability to prioritize activities according to urgency of potential utilization problems on a daily basis; adapts effectively to changing priorities. Completes work assignments on a timely basis and functions effectively with minimal supervision.
• Coordinates transfer arrangements and provides information to other facilities and third party payers such as Kaiser, non-contracting HMO's, etc.
• Works collaboratively with the patient's healthcare team to manage resources effectively according to patient needs.
• Initiates or coordinates timely and appropriate referrals for internal and external services.
• Discharge planning needs are assessed on admission and throughout the hospitalization with the appropriate resources being arranged in a timely manner.
• Maintains record of discharge planning on patient record and other required forms to substantiate continued care planning, i.e., placement attempts, requests for services and determinations made.
• Requests interdisciplinary conferences to solicit input concerning patients with medically complex issues.
• Documentation reflects compliance with established Hospital policies and procedures.
• Be in attendance on site and arrive to work on time.
• ED Care Coordinator unit-specific duties/responsibilities:
• Adjust working hours to provide for coverage for high patient census needs.
• Obtains clinical information from the ED MD and staff to ensure appropriateness of admission and level of care based on approved InterQual criteria, clinical needs and plan of care.
• Actively prevents admission denials by coordinating with ED MDs, Physicians and payers by ensuring proper documentation to support ordered care.
• Provides post ED linkages for community resources or other needs including home health, SNF placement, hospice or others as indicated.
• Screens and assists with ED transfers to and from other facilities for appropriateness and compliance with EMTALA and other regulatory agencies as indicated.
• Assists Admissions office staff to obtain accurate demographic and insurance information as needed.
• Flexes assignment to provide assistance to Acute Care Management staff as needed.
• Monitors ER Hold list for accuracy and advises appropriate staff for necessary changes.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.