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PACE Utilization Management Registered Nurse
2 months ago
Transform Lives, Strengthen Communities
Family Health Centers of San Diego (FHCSD) is dedicated to delivering outstanding health services to all individuals, particularly those in underserved populations with limited access to healthcare. Established over 50 years ago by a community advocate, FHCSD has evolved into one of the largest community health systems nationwide. With a network of over 62 locations and serving more than 227,000 patients, we are committed to providing a comprehensive range of healthcare and outreach services to a diverse patient demographic. We take pride in our mission, our enduring community impact, and the rich cultural diversity of our workforce.
Key Responsibilities
- Conduct thorough prospective, initial, and retrospective evaluations of all inpatient and facility-based skilled nursing services to determine the appropriateness and medical necessity of treatment requests.
- Monitor quality and clinical risk factors on an ongoing basis, promptly reporting any identified issues to the team and the Assistant Medical Director.
- Provide proactive contributions to care plans aimed at managing chronic and acute conditions, with the goal of enhancing quality outcomes and reducing costs.
- Effectively manage both acutely and chronically ill patients to improve health outcomes and minimize expenses.
- Collaborate with the Assistant Medical Director to assess and offer feedback to treating physicians regarding discharge and home care plans, including identifying alternative care levels that may be covered.
- Establish and maintain strong professional relationships with external contracted providers, case managers, and admissions personnel.
- Review medical records for completeness and alignment with treatment plans to identify any gaps or barriers.
- Facilitate continuous communication between staff and contracted providers to ensure timely and efficient authorization processes.
- Coordinate necessary care and services, including hospitalization, skilled care, home health, and durable medical equipment, while making referrals to external resources as needed.
- Identify and report potential high-cost utilization cases.
- Collaborate with Quality Assurance to prepare compliant notification letters regarding non-certified services and review all related documentation for accuracy.
- Support an interdisciplinary approach to ensure continuity of care, providing utilization management, transfer coordination, discharge planning, and necessary authorizations for covered services.
- Assist in identifying and reporting potential quality of care issues, ensuring these are communicated to the Quality Improvement Department.
- Investigate and follow up on complaints, grievances, and quality concerns related to patient stays.
- Participate in Utilization Management team meetings, discussing evidence-based care options with providers and suggesting alternative care levels.
- Perform additional duties as assigned.
Qualifications
- Current California RN license.
- Preferred: BSN or MSN degree.
- Ability to travel as needed within San Diego County, including areas with limited public transportation access; proof of vehicle insurance is required.
Experience and Skills
- 2 - 4 years of experience in a managed care health plan or in utilization review, case management, and discharge planning.
- 2 - 4 years of experience in transitional care and acute care settings.
- Knowledge of Managed Care Health plans, Medi-Cal/Medicaid, and/or Medicare is essential.
- Ability to work independently and collaboratively as part of a team.
- Strong multitasking skills related to various projects and their timelines.
- Preferred:
- Familiarity with PACE regulations.
- Understanding of healthcare service delivery principles and practices.
- Experience in auditing and analyzing utilization management productivity and quality.
- Knowledge of the senior care market, including regulations and available resources.
- Experience applying InterQual criteria or other evidence-based medical guidelines.
#Nursing
In the spirit of pay transparency, we are pleased to share the base salary range for this position, exclusive of fringe benefits or potential bonuses. The expected salary range is $71,000 - $87,000. Your final base salary will be determined based on factors such as geographic location, skills, education, and experience. We emphasize pay equity and consider the internal equity of our current team members in final offers. Please note that the mentioned range reflects what we reasonably expect to pay for this role, and hiring at the maximum of the range is not typical to allow for future salary growth. We also provide a comprehensive compensation and benefits package.
