UM Specialist - San Diego, United States - Sharp Healthplan

Sharp Healthplan San Diego, United States

3 weeks ago

Description

Hours

Shift Start Time:
8 AM

Shift End Time:
4:30 PM

Additional Shift Information:
8 hour shifts

Weekend Requirements:
No Weekends

On-Call Required:
No

Hourly Pay Range (Minimum - Midpoint - Maximum):
$ $ $53.657

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.

The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do

To provide comprehensive utilization management and coordination of care for members who are confined to skilled nursing facilities (SNF) in collaboration with designated SNF physician or Sharp Community Medical Group primary care physician, as appropriate to ensure cost effective quality service throughout the continuum of care.

Required Qualifications

Other : Graduate of an accredited Licensed Vocational Nurse (LVN) program
3 Years experience in the acute patient care and/or SNF setting.
California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians -REQUIRED

Preferred Qualifications

Experience as a case manager or discharge planner interacting with managed care payers.

Essential Functions

Act as a resource

Facilitates direct admissions to SNF from the Emergency Room, Physician offices, or home coordinating with the SNF admission liaison for authorization of level of care as appropriate.

Assists with transfers to SNF of Medical Group members from Out of Network (OON) and /or Out of Area (OOA).

Census and rounds

Reviews and updates SNF daily census log, adds new patients and makes corrections when needed reconciling patients/facility location, HP information and SNF benefits.

Reviews every patient under assigned workload one business day and assigns an LOS based on MCG, prior level of function, comorbidities, and discharge goals.

Rounds and /or reviews with the Sharp Extended Care (SEC) provider on site and/or telephonically.

Keeps SEC Nurse Supervisor or SEC provider of any adverse development, delay in discharge or services, readmissions to acute or visit to the ER.

Attends and participates in SNF rounds, and/or patient care conferences as appropriate.

Attends clinical in-services or required operational/clinical training sessions.

Informs quality department of any quality issues.

Chart review

Performs a comprehensive review of medical history, doctor's orders, progress notes, therapy notes, vital signs sheet, laboratory results, discharge planning notes and other pertinent medical information to determine whether patient is meeting skilled care criteria based on MCG Recovery Care Guidelines and Healthplan SNF guidelines.

Performs data entry related to patient management activities using the IDX computer system per departmental guidelines.

Complies with contracted health plan requirements for documentation of concurrent SNF review and utilization management activities performed in a manner consistent with Medical Groups' policies and procedures.

Assists in obtaining medical information necessary for activities related to Medical Groups' Quality and Appeals processes.

Demonstrates knowledge of department policies and procedures

Authorizes appropriate care levels, i.e. sub-acute, short term SNF or custodial. as well as services and supplies through patient's medical group (or health plan, as applicable).

Provides authorization as needed for DME or other services for post skilled nursing facility placement or home care.

Ensures compliance with all applicable regulatory and health plan guidelines for issuance of notice letters i.e. Medicare notice of non-coverage, Commercial notice of non-coverage or Exhaustion of Benefit etc. Assures that letters are issued accurately and served timely to members or responsible party.

Identifies services that are not medically necessary and/or not covered benefits and accurately follows Health Plan and/or Medicare Guidelines when issuing denials.

Ensures that all denials for medical necessity are issued under the direction of the appropriate Medical Group Physician Representative.

Identifies patients going into custodial level of care and appropriately recording changes in level of care in IDX per Medical Group guidelines.

Collaborates with Medical Group Appeals on members with SNF services under appeals process.

Reviews SNF claims for medical necessity and appropriateness when any information on the claim is disputed and claims department is requesting verification.

Plan of care

Works collaboratively with the Hospitalist Care Team and Care Management staff to ensure smooth transitions through out the continuum of care.

Communicates with patient, their family, the physician and the interdisciplinary team as appropriate regarding insurance coverage, discharge planning support, and post discharge care needs.

Performs discharge planning function based on specific SNF specific protocols or promotes timely assessment of discharge planning needs by the facility.

Facilitates timely referral to social work and/or patient financial services for financial screening on patients requiring long term custodial placement.

Accurately documents patient's clinical condition and maintains detailed, accurate, and timely data files on each patient.

Assigns and documents level of care based on SHC contracts and/or MCG Recovery Care Guidelines.

Communicates and collaborates with SNF physician and SNF team to explore alternative care option if patient does not meet skilled level of care.

Makes appropriate referral to Medical Groups' Care Management programs.

Communicates with the appropriate Quality Management Department regarding any quality of service or quality of care issues encountered in the course of review.

Collaborates with the Medical Groups Pharmacy Benefits Administration regarding appropriate post-discharge pharmaceutical needs or complex pharmacy-related care management needs.

Knowledge, Skills, and Abilities

Knowledge and experience in MDS and PDPM
Understanding of the federal and state regulations governing SNFs.
Knowledge and ability to utilize community resources. Knowledge of and experience with on-line computer systems.
Excellent verbal and written communication skills; strong interpersonal skills.
Ability to work independently and effectively with physicians, SNF staff, health plans, department staff, physicians and various members of the health care team.
Knowledge of available community resources and current standards of clinical practice.
Knowledge of managed care, Health Plan contracts, and benefits.
Experience with MCG Guidelines.
Understanding of the ICD and CPT coding.
Ability to carry out review activities in conjunction with Health Plan contracts, Health Plan benefit guidelines, and Medicare Guidelines. Ability to identify medically necessary care and offer alternatives for quality, cost effective care when services cannot be authorized.
Good computer skills.
Strong organizational skills.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

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