Looking for LVN/RN for case
Area : Anaheim
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 (Milliman) and
Work under the direct
supervision of UM/Case Management Manager and Medical Director.
management activities to ensure that patients move through the continuum of
care efficiently and safely.
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
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.
according to established standards.
to non-standard requests and problems.
complex problems and / or conducts moderately complex analyses.
Works with minimal
guidance; seeks guidance on only the most complex tasks.
and information to others on difficult issues.
Acts as a resource for
others with less experience.
Works with less
structured, more complex issues.
unrestricted RN or LVN License in the State of California.
3 years of clinical
experience in an inpatient / acute setting.
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.
skills - Proficiency with Microsoft Word, Outlook and Internet Explorer, with
the ability to navigate a Windows environment.
1 year Utilization
Management Inpatient experience.
Knowledge of or
experience with Milliman Care Guidelines.
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