PACE Utilization Management Registered Nurse
2 weeks 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 healthcare access. 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 prospective, initial, and retrospective evaluations on all inpatient and facility services to determine the appropriateness and medical necessity of treatment requests.
- Evaluate quality and clinical risk factors on an ongoing basis, promptly reporting any identified issues to the team and the Assistant Medical Director.
- Actively contribute to participants' care plans for managing chronic and acute conditions, aiming to enhance quality outcomes and reduce costs.
- Effectively manage patients with acute and chronic illnesses to improve quality outcomes and minimize expenses.
- Collaborate with the Assistant Medical Director to assess and provide feedback to treating physicians regarding participants' discharge and home care plans, including identifying alternative covered services.
- Establish strong collaborative 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 ongoing communication between staff and contracted providers to ensure timely and efficient authorization processes.
- Coordinate necessary care and services (hospitalization, skilled care, home health, DME, etc.), including referrals to external resources.
- Identify and report potential high-cost utilization cases.
- Work 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, including utilization management, transfer coordination, discharge planning, and issuing necessary authorizations for covered services.
- Assist in identifying and reporting potential quality of care issues 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 proposing alternative care levels.
- Perform additional duties as assigned.
Qualifications
- Current RN license in California.
- Preferred: BSN or MSN degree.
- Ability to travel as needed within San Diego County, including areas with limited public transportation access; proof of liability and property damage insurance for the vehicle used 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 (critical care, acute hospital care, long-term acute care, skilled nursing care, long-term care).
- 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.
- Proficient in managing multiple projects and their respective timelines and issues.
- Preferred Skills
- Familiarity with PACE regulations (state and federal).
- Understanding of healthcare service delivery principles, managed care, healthcare systems, and medical administration.
- Experience in auditing and analyzing productivity and quality in utilization management.
- Knowledge of the senior care market, including competitors, regulations, and available resources.
- Experience applying InterQual criteria or other evidence-based medical criteria.
#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 for this role is $71,000 to $87,000. Final compensation will be determined based on factors such as geographic location, jurisdictional requirements, skills, education, and/or experience. We value pay equity and consider the internal equity of our current team members as part of any final offer. Please note that the range mentioned above reflects what we reasonably expect to pay for the role, and hiring at the maximum of the range would not be typical to allow for future salary growth. We also provide a comprehensive compensation and benefits package.
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