RN Case Manager in Ontario, CA at Prime Healthcare

Date Posted: 8/30/2019

Job Snapshot

Job Description



Overview

Responsible for the quality and resource management of all authorizations and referrals with the Prime Healthcare Employee EPO. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and insure the achievement of quality, clinical and cost effective outcomes and to perform a holistic and comprehensive review of the medical record for the medical necessity, intensity of service and severity of illness.

Responsibilities

Upholds and supports the philosophy, objectives, and policies of PHC. Performs authorizations, referrals and post-authorization reviews in a timely manner utilizing criteria approved by the CMOs and VP of Employee health. Determines priorities for the order in which members need to be authorized. Applies appropriate clinical judgment in the concurrent review process to ensure that information in the medical records meets the criteria for intensity of care level of service for those members with continued hospital stay and/or discharge. Documents all deviations from criteria for timely authorizations and referrals and promptly discusses these with the VP of Employee Health Communicates daily, as needed, with the VP of Employee Health, or his designee, regarding timely authorizations and referrals and/or difficulties with resource utilization. Participates actively in resource planning to assure timely functioning of the UM Department. Obtains needed information regarding clinical course of member, level of service and PHC coverage. Abides with HIPAA regulations. Attends regularly scheduled staff meetings including other department required meetings and educational programs. Assists in the orientation process for new PHC Employee Health staff. Integrates with various departments in order to enhance function of PHC health plans. Assists with general office duties, i.e., copying, faxing, mailing, filing, data entry, etc. when requested. Interacts with hospitals, physicians, groups and other providers to expedite authorizations for appropriate medical care. Provides necessary documentation and communication to avoid appeals whenever possible. Performs retro reviews, when requested, on members when retro-authorizations or appeals are requested. Participates proactively in the goals and objectives of the Utilization Management Department in reducing medically aberrant LOS, and establishes personal goals to achieve desirable outcomes organizationally. Functions and collaborates with readmission reduction team goals. Performs other duties as assigned or required.

 

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Qualifications


  • Minimum 7 years Post Graduate of an accredited school of nursing and a current state Registered Nurse license.

  • Minimum 3 years RN Case Manager working for a Health Plan.

  • Five years acute care nursing experience preferred. At least 3 years experience in utilization review, referrals, authorizations, denials and appeals.

  • Experience with self-funded health plan preferred.

  • Current BCLS (AHA) certificate upon hire and maintain current;

  • Knowledge of MCG Criteria and/or InterQual Criteria required.

  • Experience and knowledge in basic to intermediate computer skills.


 

We are an Equal Opportunity/Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics.  If you need special accommodation for the application process, please contact Human Resources.  EEO is the Law: http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf