- Supervises the assigned team, overseeing daily operation of the outpatient review process.
- Provides leadership, direction, resources, training, and support as necessary.
- Provides performance feedback to the assigned UM staff and conduct staff trainings as needed.
- Participates in the interview process of new hires.
- With UM Team Manager, conducts annual performance evaluations for assigned UM staff.
- Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC CMS regulatory requirements, PHC policies and procedures, and InterQual for each product line.
- Documents and maintains patient-specific records in the PHC computer system, Essette, and in databases and files as applicable.
- Assists in the refinement/improvement of the Health Services 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.
- This position, in addition to his or her own case load, may be assigned cases in the area of oversight as deemed necessary to provide coverage.
- Communicates regularly with Team Manager/UM and works collaboratively to resolve personnel and workflow issues.
- Seeks manager assistance as needed while coordinating work, making decisions, and handling questions or problems.
- Participates in special projects and assignments as required.
- Provide the highest possible level of service to clients;
- Promote teamwork and cooperative effort among employees;
- Maintain safe practices; and
- Abide by the HealthPlans policies and procedures, as they may from time to time be updated.
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Outpatient Nurse Supervisor - Fairfield, United States - Partnership HealthPlan of California
Description
Overview:
Provide supervisory oversight during the daily operations of the outpatient review process. Supervise and train assigned team members. Provide leadership, support, resources, and direction to staff. Assist in determining appropriateness, quality, and medical necessity of requested service.
Responsibilities:Education and Experience
RN with 3-5 years experience to include staff supervision; one (1) year
managed care (case management) experience; or equivalent combination of education and experience. General knowledge of managed care with emphasis in case management preferred.
Special Skills,
Licenses and
Certifications
Current California RN license. RN Supervisor will be supervising both RN and LVN staff. 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 drivers license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
Performance
Based
Competencies
Excellent written and verbal communication skills with ability to read and interpret benefit contract specifications. Ability to understand and follow established criteria and protocols used in managed care functions. Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses. Ability to apply judgment to complex medical situations and make quick decisions. Ability to communicate effectively with coworkers, members, their families, physicians, and health care providers.
Work 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:
HIRING RANGE:
$ 120, $ 156,735.06IMPORTANT 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
