UM RN Case Management
2 months ago
Under the direction of the Senior Vice President of Health Services, this position is responsible to perform a wide variety of duties including reviewing all referrals for ambulatory care services, elective inpatient services, and durable medical equipment. This will be achieved using established criteria and Health Plan benefit guidelines in conjunction with the Medical Director and support staff in Utilization Management. The Utilization Management RN Case Manager will interact with other departments, clinic personnel, and outside providers in a professional and friendly manner, to create and maintain a positive relationship with our internal and external customers.
1.1 Coordinate the UM process in conjunction with criteria established by health plans CMS, Milliman, lnterQual and HPN Clinical Services.
1.2 Applies and follows CMS and health plan regulation benefit and criteria hierarchy in regard to requested services.
1.3 Within specific guidelines and procedures; uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies and procedures to provide the best and most appropriate treatment, care or services for members.
1.4 Obtain and document all pertinent information in regard to individual referrals utilizing pertinent guidelines established by the health plan, CMS, or nationally approved guidelines.
1.5 Serve as clinical liaison for the Utilization Management Department bringing necessary issues to the Medical Directorand UM Management.
1.6 Maintain patient safety and HIPAA guidelines.
1.7 Coordinate, identify and review complex cases with Medical Director and Utilization Management leadership team.
1.8 Available for direct communication with physicians or members in regard to questions regarding the Utilization Management process.
1.9 Identify problems within the UM process and provide solutions.
1.10 Maintain a positive and team-oriented attitude for the benefit of staff morale.
1.11 Maintain current and accurate knowledge of denial letters and the process that needs to be followed in regard to those letters.
1.12 Promote and encourage teamwork and pride among staff members regarding Utilization Management functions andcultivate good interdepartmental relationships.
1.13 Be aware of changes to Utilization Management Process and the possible effects on referral processing.
1.14 Run Crystal Reports to show daily aging and work with Utilization Management staff to ensure daily compliance with turn-around times.
1.15 Work with the Denial Coordinator in the writing of denial letters for our members.
1.16 Collaborate with the Medical Director to ensure proper services are approved for our members.
1.17 Communicate with Provider Relations regarding needs for Letters of Agreement when referrals are approved to non- contracted providers.
1.18 Communicate changes with provider referral patterns with Medical Director and Utilization Management leadership team.
1.19 Work with Customer Service to handle patient and provider complaints.
1.20 Attend and participate in staff meetings and in-service learning events.
1.21 HPN Compliance training annually.
1.22 Language and Cultural Linguistics training annually.
1.23 Other duties as assigned
Requirements
8.1 Graduate from an accredited school of Nursing.
8.2 Valid licensed Registered Nurse (RN) in the state of California.
8.3 Three years acute hospital experience required.
8.4 Previous Case Management and/or Utilization Management experience, recommended.
8.5 Experience working with CMS, health plan, MCG, lnterQual and clinical based criteria, preferred.
8.6 Excellent written and oral communication skills.
8.7 Ability to make independent decisions with moderate
8.8 Computer knowledge, preferred.
The pay range for this position at commencement of employment is expected to be between $48.60 and $57.18 however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience.
If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
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