Description

•​ ​Responsible for utilization management,
utilization review, or concurrent review (telephonic inpatient care
management)


•​ ​Perform reviews of current inpatient
services and determine medical appropriateness of inpatient and outpatient
services following evaluation of medical guidelines (MCG) and benefit
determination


•​ ​Perform medical necessity and level of care
reviews for requested medical services and refer to Medical Directors for
review as appropriate depending on case development


Responsibilities and Duties


•​ ​Performing care management activities to
ensure that patients move through the continuum of care efficiently and
safely


•​ ​Assesses and interprets customer needs and requirements


•​ ​Reviewing cases and analyzing clinical
information in conjunction with Medical Directors to determine the
appropriateness of hospitalization
•​ ​Performing Nurse to Physician interaction to
acquire additional clinical information or discuss alternatives to current
treatment plan


•​ ​Escalating cases to the Medical Director for
case discussion or peer-to-peer intervention as appropriate


•​ ​Performing anticipatory discharge planning
in accordance with the patient`s benefits and available alternative
resources


•​ ​Referring patients to disease management or case management programs


•​ ​Assisting with the development of treatment plans


•​ ​Documenting activities according to established standards

•​ ​Identifies solutions to non-standard requests and problems

•​ ​Solves moderately complex problems and / or
conducts moderately complex analyses

•​ ​Works with minimal guidance; seeks guidance on only the most complex tasks

•​ ​Provides explanations and information to others on difficult issues

•​ ​Acts as a resource for others with less experience

•​ ​Works with less structured, more complex issues

•​ ​Update and review the case management and
utilization management policies and procedures as needed


•​ ​Oversee the outpatient UM department


•​ ​Work on health plan initiated audits related
to case management, utilization management, and related audits


•​ ​Submit and implement corrective action plans
for issues identified during health plan audits


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Qualifications and Skills


Basic Qualifications
•​ ​Current and unrestricted RN or LVN License in the State of California

•​ ​Clinical experience in an inpatient / acute setting


•​ ​Problem solving skills; the ability to systematically
analyze problems, draw relevant conclusions and devise appropriate courses
of action


•​ ​Excellent verbal and written communication
skills; ability to speak clearly and concisely, conveying complex or
technical information in a manner that others can understand, as well as
ability to understand and interpret
complex information from others


•​ ​Intermediate computer skills - Proficiency
with Microsoft Word, Outlook and Internet Explorer, with the ability to
navigate a Windows environment


​

Preferred Qualifications


•​ ​1 year Utilization Management Inpatient experience

•​ ​Utilization Review experience

•​ ​Knowledge of or experience with Milliman Care Guidelines

•​ ​Experience in discharge planning or chart review

•​ ​Experience in acute long term care, acute
rehabilitation, or skilled nursing facilities
•​ ​A background that involves utilization
review for an insurance company or in a managed care environment

Resume submission : info330amm@gmail.com