Assesses plans and coordinates optimal and timely care delivery for Community Health Group (CHG) members along the entire continuum of care. Responsible for ensuring that ongoing services being utilized for patient care continue to meet the guidelines for that level of care. Participates in Utilization Management (UM)/Case Management (CM) quality and outcome monitoring.
COMPLIANCE WITH REGULATIONS
>Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS and DHMC.
Uses clinical judgment to review, monitor, and coordinate requests for services, proposed surgical procedures, and specialty services requests by utilizing CHG-approved clinical guidelines and benefit structures; reviewing clinical reports and records, electronically or paper; determining medical necessity of proposed procedures; coordinating services at the appropriate level of care; communicating decisions to primary care practitioners.
Coordinates reviews not meeting pre-certification guidelines with Medical Director or Chief Medical Officer for determination.
Applies standard, plan designated clinical guidelines to monitor, review and coordinate proposed services for adult and pediatric populations; and screens for under and over utilization.
Forwards quality of care concerns to QI using criteria for identification of these cases; assist with QI studies; provides case-specific follow-up for pre determined cases.
Collaborates with providers of care, patient and significant others to arrange for alternative care.
Utilizes pharmacy, Emergency Room (ER) encounter history, and admission history summaries to assist providers in developing a transition/discharge plan which includes members total potential discharge needs.
Refers catastrophic and targeted disease management cases to appropriate Case Manager.
Reviews or assist in reviewing policies and workflow at least annually. Participates in Quality Improvement Activities (QIA) activities that would identify conditions appropriate for Disease Management (DM) efforts.
Under the direction of supervisor, researches and assists in the implementation of processes surrounding workflow and internal guideline development designed to enhance member outcomes and increase customer satisfaction.
Attends department meetings; provides feedback for existing processes; maintains patient confidentiality; represents department in interdepartmental and external meetings and forums regarding each area of expertise.
Functions as a resource to internal and external customers by developing relationships with staff at assigned hospitals, skilled nursing facilities, clinics, and delivery care providers in order to facilitate and improve transitions and coordination of care. Provides education to members and providers on available resources to members. Offers assistance to peers when needed.
Graduate from an accredited school of nursing.
Registered Nurse (RN) in CA (active and unencumbered status); current drivers license and proof of auto insurance.
BSN degree in nursing or other health related field and certification in utilization review and/or case management preferred.
Foreign medical graduates, health education or other mental/social health discipline (a combination of experience and education will be considered in lieu of degree in nursing).
3 years experience working in an acute care facility (ICU, emergency department, and/or medical/surgical unit) and 1 year experience in a managed care environment.
Inpatient discharge planning, high risk management experience or outpatient referral management preferred.
Working knowledge of Microsoft Word programs.
Knowledge of managed care principles, CPT, ICD-9, ICD-10, HCPCS coding, experience with inpatient and outpatient medical review guidelines (Milliman USA, Interqual). Familiar with Medi-Cal, Medicare. Familiar with Web based standard of care sites i.e. NIH, ACOG.
Ability to communicate effectively verbally and in writing; exceptional telephone and customer service skills; ability to establish effective working relationships with physicians and medical professionals; ability to organize work effectively, determine priorities, and work well independently.
Bilingual in English and Spanish preferred.
Prolonged periods of sitting at desk; intermittent standing, walking, bending, stooping, lifting 10 lb. or less.
May be necessary to work and attend meetings outside of facility or normal business hours.