Lead, Inpatient UM Nurse Capped
3 weeks ago
Summary
Provides leadership, support, training, and direction to the Inpatient UM teammates. The incumbent will use clinical judgment to provide utilization management review for inpatient during high volume situations. Provide high quality, cost-effective care to enable patients to achieve maximum medical improvement, while receiving care deemed medically necessary.
Duties and Responsibilities
· Conducts review of the TMs timecard (T&A) and 30-days, 60-days, 90-days, 6-month, and annual performance evaluations for assigned UM TM’s. Provides performance feedback to the UM staff and conducts staff trainings as needed.
· Provides leadership, direction, training, and support to the assigned team and remote Inpatient UM staff.
· Assists in the development and updates department Policies and Procedures, Workflows, and SOP’s as needed.
· Assists in organizing and coordinating Team Meetings and plans team building exercises. Assists in research and gathering of details needed for HP CAP responses; reinforces MPM Policies and provides Corrective Action Plans to staff when needed
· Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC and/or CMS regulatory requirements, and IPA policies and procedures for each product line.
· Leads the clinical review process for assigned team and assigned remote Inpatient UM staff and escalates any issues identified during rounds to the Inpatient UM Supervisor
· Monitors daily workload, daily open cases for nurses to assess and determine staffing needs
· Ensures minimum productivity standards are met, including assisting with current workload when timely review and/or discharge may be in jeopardy.
· Works with other MPM departments to resolve issues relating to authorization of medical services and assists Inpatient UM staff with member’s grievances.
· Leads Inpatient UM staff with the daily huddle with hospitalist, Medical Directors for Outlier Cases: for acute and Skilled Nursing Facility (SNF)
· Assists nurses in identifying and referring eligible cases to the Re-admission Team, Case Management, Transition of Care, Behavioral Health, Post-Discharge Clinics or other internal or external programs (i.e. MedZed, Enhanced Care Management, Community Support services, CAW, Landmark) as needed.
· Reviews Denial Verbiage for nurses to ensure accuracy before Denials are sent to the Denial Team for processing with guidance from the Inpatient UM Nurse Supervisor as needed.
· Provides oversight of DENCs and NOMNCs to ensure accuracy and compliance.
· Responsible for coverage for vacation relief and sick calls, will have modified work assignment.
Minimum Job Requirements
· Knowledgeable of all MPM databases, proper usage, and date fields/ logic used by their team.
· Current RN or LVN licensure; Preferred: BSN level of education.
· Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review/quality assurance, use of Milliman or other clinical decision support criteria, discharge planning, and reimbursement structures (i.e. Government and non-governmental payers).
Skill and Abilities
· Excellent notetaker with the ability to relay large amount of information in a digestible format and ability to efficiently scrub data to understand errors and/ or key assumptions.
· Ability to identify improvement opportunities and set realistic goals for the TM’s to achieve and mentor TM’s as a coach and tailor their style to each TM personally.
· Ability to communicate effectively with direct TM’s both in meetings and written communication, wide range of hospital personnel, physicians, patients/family members within various socioeconomic groups and representatives of varied outside agencies.
-
Lead, UM Delegation Oversight
1 month ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionThe Lead of UM Delegation Oversight reports directly to the Sr. Supervisor of UM Delegation Oversight. The Lead of UMDO is directly responsible for the oversight and monitoring of the UM audit activities. This includes ensuring audit functions are operating efficiently, focused on continuous improvement, and per the team's...
-
Supervisor, UM Delegation Oversight
2 weeks ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionSummaryThe UMDO Supervisor’s primary responsibility is to oversee and strategize the day-to-day operations of UM Compliance and NOA Operations. The Supervisor will report directly to the Sr. Supervisor of UM Delegation Oversight. Duties and Responsibilities· Oversight of the effective, timely, and compliant support for all...
-
Inpatient UM HLOC
2 weeks ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionSummaryOversees the higher level of care cases and the process and the management of our inpatient transplant cases. Will be responsible for answering any questions the inpatient nurses might have during their shift with the direction of the Lead La Care Shared Risk Nurse, and Medical Directors. Provides overall coordination in...
-
Inpatient UM HLOC
6 days ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionSummaryOversees the higher level of care cases and the process and the management of our inpatient transplant cases. Will be responsible for answering any questions the inpatient nurses might have during their shift with the direction of the Lead La Care Shared Risk Nurse, and Medical Directors. Provides overall coordination in...
-
Out-Patient UM Clinician
1 month ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionSummaryReporting to the Outpatient Lead Clinician, the Outpatient UM Clinician is responsible for assuring a thorough review of outpatient precertification/preauthorization referrals for those members identified as having the need for outpatient services. The OP UM Clinician works closely with Medical Director to determine and...
-
UM Member Liaison
1 month ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionSummaryThe UM Member Liaison acts as an advocate on behalf of the member to address any concerns or questions they may have regarding their medical care relationship(s) with providers. The Liaison also works closely with the health plans with member assignment and access to care. The UM Member Liaison reports directly to the...
-
Out-Patient UM Clinician
1 month ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob Description SummaryReporting to the Outpatient Lead Clinician, the Outpatient UM Clinician is responsible for assuring a thorough review of outpatient precertification/preauthorization referrals for those members identified as having the need for outpatient services. The OP UM Clinician works closely with Medical Director to determine and...
-
Um Prior Auth Nurse
4 weeks ago
Los Angeles, United States MV Medical Management Full timeUtilizes decision-making and critical-thinking skills in the clinical review and determination of coverage for medically necessary health care services based on established hierarchy of criteria Knowledge of California Children Services (CCS) Knowledge of Health Plan DOFR's Maintain Compliance and CMS regulatory standards Follow UM Policies &...
-
Compliance Coordinator
1 week ago
Los Angeles, United States MedPOINT Management Full timeJob Description Job Description Summary MedPOINT Management is committed to conducting its business and operations in accordance with the highest legal and ethical standards. Our Code of Conduct sets forth our expectations of management, employees, and contractors to act in accordance with applicable laws and Company policy. MedPOINT’s Compliance...
-
Compliance Coordinator
1 month ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionSummaryMedPOINT Management is committed to conducting its business and operations in accordance with the highest legal and ethical standards. Our Code of Conduct sets forth our expectations of management, employees, and contractors to act in accordance with applicable laws and Company policy. MedPOINT’s Compliance Department...
-
Outpatient UM Coordinator
2 months ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionSummaryThe Outpatient UM Coordinator provides effective communication between MSO, IPA providers, and members to coordinate member care. Communication to include accessibility to care, validating contract entities, and ensuring timeliness standards are met. The Outpatient UM Coordinator reports directly to the Outpatient Lead...
-
Outpatient UM Coordinator
2 months ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionSummaryThe Outpatient UM Coordinator provides effective communication between MSO, IPA providers, and members to coordinate member care. Communication to include accessibility to care, validating contract entities, and ensuring timeliness standards are met. The Outpatient UM Coordinator reports directly to the Outpatient Lead...
-
In Patient Nurse Case Manager
1 month ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob Description MedPOINT ManagementTitle: Inpatient Nurse - Delegated Plans =====================================================================================MedPOINT, a large MSO in the San Fernando Valley offers competitive salaries and benefits in a collaborative working environment. For immediate consideration of this position, please...
-
Lead, NOA Operations
6 days ago
Los Angeles, United States MedPOINT Management Full timeJob Description Job Description Summary The Notice of Action (NOA) Operations Lead oversees the NOA team member’s daily workflow which is essential to successfully writing, processing, and submitting NOA letters to our patients and providers with a focus on statutory and regulatory requirements. The Notice of Action (NOA) Operations Lead reports directly...
-
Lead, NOA Operations
2 weeks ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionSummaryThe Notice of Action (NOA) Operations Lead oversees the NOA team member’s daily workflow which is essential to successfully writing, processing, and submitting NOA letters to our patients and providers with a focus on statutory and regulatory requirements. The Notice of Action (NOA) Operations Lead reports directly to...
-
Lead, NOA Operations
2 weeks ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionSummaryThe Notice of Action (NOA) Operations Lead oversees the NOA team member’s daily workflow which is essential to successfully writing, processing, and submitting NOA letters to our patients and providers with a focus on statutory and regulatory requirements. The Notice of Action (NOA) Operations Lead reports directly to...
-
Clinical Liaison, Client Support Center
3 weeks ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionReporting to the Supervisor, Client Support Center and VP, Quality Management, the Clinical Liaison is responsible for assisting client support TMs with IPA approval workflows that require escalation, expedited handling or additional clinical information to finalize authorizations. Duties and Responsibilitieso Assist Client...
-
Clinical Liaison, Client Support Center
2 weeks ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionReporting to the Supervisor, Client Support Center and VP, Quality Management, the Clinical Liaison is responsible for assisting client support TMs with IPA approval workflows that require escalation, expedited handling or additional clinical information to finalize authorizations. Duties and Responsibilitieso Assist Client...
-
Health Plan Liaison
5 days ago
Los Angeles, United States MedPOINT Management Full timeJob DescriptionJob DescriptionThe Health Plan Liaison is the main point of contact between Outpatient UM team members and Health Plan personnel. This role oversees referral requests that are delegated to the Health Plans (i.e. tertiary, DME, pharmacy, etc.), from the initial provider request until the final decision from the Health Plan is made. Reporting to...
-
CalArts CAP Visual Arts Lead Instructor
1 month ago
Los Angeles, United States CalArts Community Arts Partnership Full timeJob DescriptionJob DescriptionSalary: After-School Instructor - Visual ArtsCAP, a co-curricular program of CalArts, offers free arts programs for youth ages 4-18 in every discipline taught at the institute. CAP is dedicated to strengthening relationships with communities across the county, including high-need and systemically underserved areas. Position...
