Nurse Coordinator/ um I - Fairfield, United States - Partnership HealthPlan of California

Partnership HealthPlan of California

Verified Company

Fairfield, United States

1 week ago

Posted by:

Mark Lane

beBee recruiter

Description

Overview:
The incumbent utilizes clinical judgement in providing utilization management services.

The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary.

Assists in determining appropriateness, quality and medical necessity of treatment plans using pre-established guidelines. This position may be assigned cases in long-term care and ancillary, DME or medical services.

Responsibilities:

Conducts retrospective claims review, either in the aggregate or on an individual basis. Provides summaries of findings to the Team Manager UM.
Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC and/or CMS regulatory requirements and PHC policies and procedures for each product line.
Recommends and coordinates interventions to facilitate high quality, costeffective care, monitoring treatment, progress and outcomes of patients.
Documents and maintains patientspecific utilization management records in database and files.
Assists in the refinement/improvement of the HS programs. Participates in continuous process improvement endeavors.
Works with other PHC departments to resolve issues relating to authorization of medical services.
Audits medical records as appropriate.
Performs interrater reliability audits as directed by department manager.
Elicits medical information from providers and medical records and applies clinical judgement to determine medical necessity and provide timely reports/authorizations for recommended treatment.
Refers cases that do not meet criteria on to the PHC HS department manager, director or Chief Medical Officer as appropriate.

SECONDARY DUTIES AND RESPONSIBILITIES

Participates in special projects and assignments as required.

Qualifications:

Education and Experience

RN/LVN with 2-3 years experience to include one (1) year managed care (utilization management) experience; or equivalent combination of education and experience.

General knowledge of managed care with emphasis in UM preferred.
Special Skills, Licenses and
Certifications
Current California RN/LVN license. Strong knowledge of nursing requirements in a clinical setting. Knowledge of utilization management programs as related to use of pre-set criteria and protocols. Familiarity with business practices and protocols with ability to access data and information using automated systems.

Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines.

Strong organizational skills required. Effective telephone and computer data entry skills required.

Valid California driver's license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
Performance Based CompetenciesWork Environment And Physical Demands**Daily use of telephone and computer for most of the day.

Cubicle work station. Ability to use a computer keyboard. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs.

All HealthPlan employees are expected to:

Provide the highest possible level of service to clients;
Promote teamwork and cooperative effort among employees;
Maintain safe practices; and
Abide by the HealthPlan's policies and procedures as they may from time to time be updated.

HIRING RANGE:

LVN:
$ $ 45.04

RN:
$ $ 56.97

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform.

The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.