Out-Patient Nurse Case Manager
Title: UM Outpatient - Utilization Nurse
MedPOINT, a large MSO in the San Fernando Valley offers competitive salaries and benefits in a collaborative working environment. For immediate consideration of this position, please e-mail your resume and salary requirements to firstname.lastname@example.org
Responsible for assuring the receipt of high quality, cost efficient medical outcomes for those members identified as having the need for outpatient precertification/preauthorization. Responsible for screening members
Duties and Responsibilities:
1. Review precertification requests for medical necessity, referring to the Medical Director those that require additional expertise.
2. As part of the UMRN triage program, conduct ongoing availability, monitoring and oversight of non-clinical staff activities.
3. Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.
4. Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:
a. Promote improved quality of care and/or life
b. Promote cost effective medical outcomes
c. Prevent hospitalization when possible and appropriate
d. Prevent complications in members under our care when possible
e. Promote Decreased lengths of hospital stays when appropriate
f. Provide for continuity of care
g. Assure appropriate levels of care are received by members
5. Provide appropriate consultation and referral to Case Management personnel.
6. Provide advice and counsel to precertification staff.
7. Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.
8. Ability to review cases using applicable criteria per line of business.
9. Maintain accurate records of all communications and interventions.
Minimum Job Requirements:
Two years of prior experience with utilization management preferable. Current CA RN/LVN License.
Knowledge, Skills and Abilities Required:
• Excellent relationship management skills, including a high degree of psychological sophistication and non-aggressive assertiveness.
• Demonstrate ability to problem solve complex, multifaceted, emotionally charged situations,
• Ability to engage easily in abstract thought.
• Medi-Cal managed care experience (CCS, VSP, VFC etc.)
• Experience in interpreting DOFR's
• Ability to successfully manage conflict, negotiating "win-win" solutions.
• Strong organizational, task prioritization, and delegation skills.
• Ability to construct grammatically correct reports using standard medical terminology.
• Patient advocacy focus.
• Proficiency with Microsoft Office Programs; primarily Word and Excel 2013 or higher
• EZ-CAP® knowledge a plus.
Woodland Hills, CA
Wed, 6 Sep 2017 15:03:44 PDT