Conducts medical reviews for necessity, level of care, and benefit reviews rendered in the inpatient and outpatient setting to ensure the patient receives the highest level of care. Coordinates with providers, provider staff, and hospital staff, patients and patient family members to establish an appropriate level of care.
EDUCATION & EXPERIENCE
- Current California RN license required.
- Five or more years of experience working in a medical facility, hospital, or otherhealthcare related environment; managed care experiencepreferred.
- Two years experienced working with a medical group or IPA preferred.
- Completion of case management certificate preferred.
- Valid CA driver’s license, current DMV printout and insurance required.
- Must meet hospital credentialing requirements to obtain facility ID.
- Bachelor’s degreepreferred.
JOB KNOWLEDGE, SKILLS & ABILITIES
- Knowledge of nursing processes, care management, and continuity of care.
- Familiarity with regulatory requirements for managed care, HMOs, and EPOs.
- Ability to apply criteria to identify appropriate level of care on all admissions and clearly document any research conducted and rationale of decisions made. Ability to identify care needs across the age continuum and according to principles of growth and development over the life span.
- Ability to apply appropriate business rules, medical guidelines and/or health plan benefits to authorization decision making.
- Proficiency with health plan criteria/benefits and regulatory requirements as they relate to patient management across the continuum of care.
- Proficient with standardized criteria, Interqual/Milliman, MCG, Medicare, etc.
- Knowledge of network and benefit limitations and ability to collaboratewith stakeholders to find alternatives that meet patient needs and achieve positive outcomes.
- Knowledge of disease management strategies.
- Basic knowledge of CPT and ICD 9/ICD 10 codes.
- Ability to interpret and communicate complex contract or benefit language.
- Willingness to work as part of a team, working collaborativelywithothers to achieve goals, solve problems, and meet established organizational objectives and management of patients.