※ 사기글 주의사항 ※
비트코인, 재무설계 등 부업을 빙자하여 수수료를 요구하는 글은 스캠이므로 절대 연락하지 마시고 신고하시기 바랍니다.
Description
• Responsible for utilization management,
utilization review, or concurrent review (telephonic inpatient care
management)
• Perform reviews of current inpatient
services and determine medical appropriateness of inpatient and outpatient
services following evaluation of medical guidelines (MCG) and benefit
determination
• Perform medical necessity and level of care
reviews for requested medical services and refer to Medical Directors for
review as appropriate depending on case development
Responsibilities and Duties
• Performing care management activities to
ensure that patients move through the continuum of care efficiently and
safely
• Assesses and interprets customer needs and requirements
• Reviewing cases and analyzing clinical
information in conjunction with Medical Directors to determine the
appropriateness of hospitalization
• Performing Nurse to Physician interaction to
acquire additional clinical information or discuss alternatives to current
treatment plan
• Escalating cases to the Medical Director for
case discussion or peer-to-peer intervention as appropriate
• Performing anticipatory discharge planning
in accordance with the patient's benefits and available alternative
resources
• Referring patients to disease management or case management programs
• Assisting with the development of treatment plans
• Documenting activities according to established standards
• Identifies solutions to non-standard requests and problems
• Solves moderately complex problems and / or
conducts moderately complex analyses
• Works with minimal guidance; seeks guidance on only the most complex tasks
• Provides explanations and information to others on difficult issues
• Acts as a resource for others with less experience
• Works with less structured, more complex issues
• Update and review the case management and
utilization management policies and procedures as needed
• Oversee the outpatient UM department
• Work on health plan initiated audits related
to case management, utilization management, and related audits
• Submit and implement corrective action plans
for issues identified during health plan audits
Qualifications and Skills
Basic Qualifications
• Current and unrestricted RN or LVN License in the State of California
• Clinical experience in an inpatient / acute setting
• Problem solving skills; the ability to systematically
analyze problems, draw relevant conclusions and devise appropriate courses
of action
• Excellent verbal and written communication
skills; ability to speak clearly and concisely, conveying complex or
technical information in a manner that others can understand, as well as
ability to understand and interpret
complex information from others
• Intermediate computer skills - Proficiency
with Microsoft Word, Outlook and Internet Explorer, with the ability to
navigate a Windows environment
Preferred Qualifications
• 1 year Utilization Management Inpatient experience
• Utilization Review experience
• Knowledge of or experience with Milliman Care Guidelines
• Experience in discharge planning or chart review
• Experience in acute long term care, acute
rehabilitation, or skilled nursing facilities
• A background that involves utilization
review for an insurance company or in a managed care environment
Resume submission : info330amm@gmail.com
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