Organization:

SPMF-Sutter Pacific Medical Foundation - South

Position Overview:

Serves as a Case Manager (CM) Subject Matter Expert (SME) performing case management roles and functions, with a focus on InterQual medical necessity reviews, training newly hired team members, quality assurance and support. Conducts group and one-on-one training sessions with peers and new hire case managers, provides constructive feedback, and assesses progress and compliance with the system standardized utilization management process and case management workflows. Schedules RN Case Manager training sessions, conducts and presents audit findings, trends and program results to staff and leaders.
May have contact with patients, families, the interdisciplinary team, nursing management, quality and ancillary services, third party payers and review agencies. Develops key relationships with Case Managers, Care Coordination leaders, and Physician Advisors, in addition to maintaining a beneficial working relationship with team members and physician leaders to assist in the clinical review process.

Job Description:

These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

JOB ACCOUNTABILITIES:

• Assesses utilization of resources to ensure cost effective care using evidence based criteria.
• Maintains Utilization Review Accuracy rate of 90% and meets productivity standards.
• Performs comprehensive chart review and utilizes InterQual criteria for potential and actual admissions, continued stay and/or retrospective reviews to determine appropriateness of the admission, setting, continued services, and level of care.
• Initiates timely communication with case managers, physicians, other staff and leaders when medical necessity deficiencies and denials trends are identified.
• Identifies and collaborates with Sutter Health on new approaches and best practice models for denials prevention.
• Monitors appropriate reports for admissions and/or continued stays requiring Utilization Review.
• Maintains current knowledge base of regulatory laws, insurance contracts, coverage and reimbursement rules for Medicare, Medi-Cal and other government and commercial payers.
• Provides training, peer reviews, quality assurance and support.
• Provides hands-on training, education and support to new hire and staff RN case managers, as required.
• Assists Care Coordination Educators with training and development activities.
• Considers adult learning styles and development levels and tailors educational approach and methods accordingly.
• Provides feedback and assesses case manager progress and compliance with established Sutter Utilization Management (UM) Process and Case Management (CM) workflows.
• Performs screening, assessment, care coordination, care transition and discharge planning activities for patients.
• Conducts InterQual and chart audits to assist with peer reviews. Provides audit results, trends and significant developments related to resource or utilization management.
• Acts as a liaison to departments for management of claims to support adjudication of all capitated claims, including acute enrollee notification submissions.
• Attends weekly conference calls with other departments to review claims for payment versus denial.
• Conducts daily reviews and provides case management for all capitated inpatients.
• Coordinates follow-up and outpatient care with capitated members’ medical group.
• Assists with coordination of second level review authorizations.
• Demonstrates a clear understanding of, and consistently adheres to System, department and facility policies, procedures and standards.
• Attends and actively participates in department and facility meetings, training and classes, including annual fire, safety, and disaster programs.

EDUCATION:

Graduate of an accredited school of nursing

CERTIFICATION & LICENSURE:

RN-Registered Nurse of California

TYPICAL EXPERIENCE:

5 years recent relevant experience.

SKILLS AND KNOWLEDGE:

Broad knowledge base of health care delivery and case management within a managed care environment.

Knowledge of utilization review process, OIG, CMS, RAC, and all other regulatory agencies related to utilization management.

Comprehensive knowledge of medical necessity standards, levels of care, inpatient and outpatient status (observation, ambulatory procedure, emergency).

Verbal and written communication skills.

Able to work with team members to produce desired goals and objectives.

Able to successfully navigate multiple computer programs for chart review, medical necessity determination, and care coordination processes.

Able to provide group and one-on-one education to new hires and peers.

Proficient in Excel spreadsheets, use of pivot tables, formulas and graphs.

Proficient in Microsoft suite including Word and Outlook.

PHYSICAL ACTIVITIES AND REQUIREMENTS:

See required physical demands, mental components, visual activities & working conditions at the following link:

Job Shift:

Days

Schedule:

Full Time

Shift Hours:

8

Days of the Week:

Monday - Friday

Weekend Requirements:

None

Benefits:

Yes

Unions:

No

Position Status:

Non-Exempt

Weekly Hours:

40

Employee Status:

Regular

Employees of Sutter Health and its entities may handle hazardous drugs in the course of their work, including patient care, which requires them to manage, store, prepare, receive, unpack, transport, dispose of, or administer drugs identified as hazardous or potentially hazardous by the National Institute for Occupational Safety and Health (NIOSH) and in accordance with the USP 800 guidelines.

The compensation range may vary based on the geographic location where the position is filled. Total compensation considers multiple factors, including, but not limited to a candidate’s experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health’s comprehensive total rewards program. Eligible positions also include a comprehensive benefits package.