Transplant Case Manager-Medical Group

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  • 19-00169
  • Direct Placement
  • Managed Care Nursing
  • Torrance, CA
Job Description
Transplant Case Manager / Medical Group
(IPA/Medical Group)

The Out of Area (OOA) and Transplant Care Manager provides evidence-based concurrent case management to support the delivery of effective and efficient member care in the acute hospital setting when members are admitted to out of area hospitals.

The role integrates utilization management, care coordination, and transition planning functions. Based on the initial review of member care needs at the time of admission, the IOO establishes a discharge/transition plan in collaboration with the facility staff, member family and/or caregivers, case management team and the hospitalist team, as appropriate.

The OOA & Transplant Care Manager supports and manages members transitioning to and from based on acuity and medical necessity in support of the hospitalist team directives.

As a member of the interdisciplinary team, the OOA Care Manager supports the hospitalist team in facilitating appropriate care for members with the objective of ensuring care is appropriate at the external facility and discharge planning is supported. When appropriate and at the direction of the hospitalist team, repatriation of members is facilitated. This may be related to member's care not progressing as expected, member needs are questionable or complex, requiring more hands-on management by the hospitalist team or member care can safely be provided at .

In this dual role, the IOOATNCM also manages members who are going through pre-transplant evaluation, transplant and post- transplant services. The IOOATNCM will maintain regular communication with transplant facilities and health plans.

  • Contacts external acute care facilities upon notification of admission of a member to a non- acute level of care facility
  • Determine if admission is or Health Plan financial responsibility based on Division of Financial Responsibility (DoFR) for language and distance from , including transplant admissions
  • If Plan responsibility to manage OOA or non-contracted admissions, notify hospital to contact plan and establish an authorization in the authorization system for 'tracking purposes only'
  • Facilitate transfers to when notified of ED member contact with stable condition at external facility when member requires admission
  • Establish communication for ongoing clinical review and support when notified of member admission to a non- acute level of care facility, including transplant admissions
  • Apply approved evidence based clinical criteria to monitor appropriateness of admissions and continued stays to ensure a clear status determination, assessing appropriateness of level of acuity and care
  • Discuss cases with the hospitalist reviewer for ongoing decision making as it relates to continued stay, discharge planning and/or repatriation
  • Arrange and/or facilitates repatriation, identified discharge plan and services of members to ensure timely intervention in an effort to prevent delays in service and transition of care
  • Present cases and participates in discussion at Interdepartmental Meetings (IDT), including transplant cases
  • Participate in case discussions with the hospitalists regarding continued stay and discharge planning needs of each member
  • Attend in person or telephonically hospitalist daily rounds
  • Identify members and families with complex psychosocial issues and refers them to the Social Worker as appropriate
  • Demonstrate skill and success in collaboration with Social Work partner
  • Document results of assessments, status assignment, and activities or interventions and discharge planning in technology systems (Patient Center®, and others, as appropriate) electronic medical record and/or alternative electronic documentation system according to departmental policies and procedures
  • Document care plan and subsequent changes in the electronic documentation system
  • Facilitate transfer to other facilities as directed by the appropriate hospitalist physician leadership
  • Initiate referrals for skilled facility admissions, home health care, hospice, and medical equipment and supplies
  • Demonstrate ability to effectively handle multiple tasks throughout the workday and to appropriately prioritize tasks
  • Demonstrate effective problem-solving techniques by resolving complaints and implementing effective solutions
  • Ability to handle multiple tasks simultaneously and set appropriate priorities
  • Adhere to privacy and confidentiality rules in accordance with the Health System, State, Federal and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations
  • Remains current with relevant healthcare requirements and the relevant professional literature
  • Collaborate and communicate with multidisciplinary team in all phases of discharge planning process, including initial member assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation
  • Follow department procedures, prepare comprehensive care plan that includes action steps and resources
  • Routinely coordinate with member and/or family regarding action plans and resources to carry out care plan recommendations
  • Communicate and coordinate with Health Plans, per contract requirements and transplant facilities to ensure members are progressing and /or take appropriate action, as needed
  • Participate in department specific initiatives and department meetings
  • Remain current with relevant healthcare requirements and the relevant professional literature
  • Follow company code of conduct
  • Perform other work as required or requested
  • Maintain a neat, clean, and orderly work area


  • Current California RN license, in good standing
  • Bachelor or Associate degree in nursing
  • Thorough knowledge of Registered Nurse (RN) scope of practice, current state requirements
  • Two (2) years acute hospital experience required
  • Two (2) years managed care experiences: utilization management or case management background required
  • Thorough knowledge of case management
  • Thorough knowledge of Registered Nurse (RN) scope of practice, current state requirements, Centers for Medicare & Medicaid (CMS) Conditions of Participation, Emergency Medical Treatment and Active Labor Act (EMTALA), The Patient Bill of Rights, AB 1203 (Post Stabilization Bill), and other Federal and State regulatory agency requirements specific to Utilization Review and Discharge Planning
  • Thorough knowledge of MS Word, Excel, Electronic health Records, Interqual, CareEnhance® Review Manager Enterprise (CERME), and/or Milliman
  • Knowledge of CMS Conditions of Participation
  • Knowledge of California state legislation related to patient management such as Emergency Medical Treatment and Active Labor Act (EMTALA), and AB 1203 (Post Stabilization Bill)
  • Knowledge of The Patient Bill of Rights
  • Working knowledge of Federal, State and local community resources, services and programs
  • Understanding of family and group dynamics
  • Familiarity with behavior modification techniques
  • Knowledge of resources in the community, laws, regulations, and policies that govern case management
  • Excellent verbal and written skills required
  • Must read, speak and write English fluently
  • Bi-lingual, English/Spanish, helpful


  • Commensurate with Experience

Additional Information

  • Full Time, M-F
  • Direct Placement; Benefited; Non-Exempt


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