The Pediatric Nurse Case Manager coordinates resources and services in response to individual patient’s needs and fiscal realities, performs utilization review activities and oversees coordination of complex discharge planning for assigned case load.  The Nurse Case Manager is an active member of the interdisciplinary team contributing to team goal setting.  The Nurse Case manager acts as a consultant to the clinical team, service lines and other departments and participates in program development and quality improvement initiatives.

The Nurse Case Manager provides age-appropriate assessments, interpretation of data, and delivery of interventions.  Demonstrates the ability to work with any patient regardless of race, gender, religious affiliation, cultural beliefs, lifestyle, and disease process or treatment plan.

Responsibilities

DUTIES & ESSENTIAL JOB FUNCTIONS

Percent

of time

Essential Function

Key Responsibilities

30

Yes

• Oversees and coordinates complex discharge planning needs for assigned patients in collaboration with other interdisciplinary team members, assuring a safe discharge plan is developed and implemented in a timely manner

• Reviews prospectively, concurrently and retrospectively all inpatients for appropriateness of admission, level of care and determines appropriate length of stay.

• Collaborates with physicians, social workers, support liaisons and other interdisciplinary team members to assess, plan and coordinate patient care needs.

• Monitors patient’s length of stay and collaborates with physicians to ensure resource utilization remains within covered benefits and are appropriate in relationship to the patient’s clinical and psychosocial needs.

• Considers age specific needs of the patient as appropriate and effectively 
  communicates and interacts with patients, families, staff and members of the community from diverse backgrounds.

20

Yes

• Educates patient / families and other healthcare providers regarding utilization management and discharge planning options.

• Provides consultation and education to members of the healthcare team, hospital departments, service lines and community agencies and providers.

20

Yes

• Performs utilization review using InterQual criteria for assigned service line.

• Participates in denial review for assigned service line.

• Acts as a liaison between insurance medical director and attending physician for peer to peer reviews in cases of denied coverage. 

• Provides the requested clinical information to insurance organizations to assure reimbursement.

10

Yes

• Participates in quality improvement activities by identifying opportunities for improvement in such areas as clinical outcomes, utilization of resources and concurrent data collection. Participates on clinical process improvement teams within the department, services lines and hospital. 

10

Yes

• Participates in department program planning including goal setting, program development, systems development and improvement. Participates in departmental work groups, hospital committees and task forces.

10

Yes

• Oversees and directs activities delegated and performed by the Support Liaison.

Qualifications

Required Qualifications

• Possesses a Bachelor’s Degree in a Healthcare related field. 
• Recent experience in case management, utilization review or discharge planning.
• Knowledge and abilities essential to the successful performance of the duties assigned to the position.
• Demonstrates resourcefulness, superior written and oral communication, diplomacy, organizational and analytic skills.
• Self-directed, assertive and creative in problem solving, systems planning and patient care management in a high volume work environment.
• Basic computer skills
• Ability to work effectively and collaboratively with interdisciplinary teams.
• This position requires flexibility to orient and work at all UCSF Medical Center locations.

Preferred Qualifications

• Master’s Degree in Nursing or Healthcare related field preferred.

Required License/Certifications

• California Registered Nurse License (RN)