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

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