RN Case/Care Manager
Location:
Grass Valley , California
Posted:
February 08, 2017
Reference:
1488709647










This position is to support the Network Inpatient Initiatives to improve our member's transition and outcomes throughout the inpatient care process. The position will have the below main functions:
1. This position will allow for a more flexible response to increased work volume, staffing challenges and improved discharge and transition of care planning. Network Nurse Case Manager covers duty assignments as directed for various IPA's. Coverage assignments are directed to assist with new Medical Management Network Inpatient Initiatives across the Network along with cover of nurse case managers who are on PTO, leave, or assigned other temporary duties etc...
Network Nurse Case Manager covers duty assignments as directed for various IPA's. Coverage assignments are directed to cover nurse case managers who are on PTO, leave, assigned other temporary duties etc. Most assignments are temporary and are directed to support multiple IPA staffing needs. Duties are relegated to fill in for Concurrent Review Case Managers at local Acute Hospitals, Skilled Nursing Facilities and Pre-Certification Authorization/referral review Nurse duties. Assignments can be either in a hospital setting or at the IPA/Medical Group Office. **Under the prior experience below if candidate has strong experience in only one area will consider for position.
Qualifications
Ø CA Licensed RN or LVN
Ø 1 - 2 years managed care experience
Ø 1 plus years nursing experience in an Acute Hospital setting (Med/Surg, Tele, ICU) or like setting.
Ø Willingness to work at various job sites dependent on Network needs

Needed Prior Experiences
Ø Ability to perform concurrent review case management of patients in an Acute or SNF setting (utilization/clinical review and discharge planning)
Ø Ability to perform prior authorization/referral case management duties in the managed care setting (Specialty MD referrals, DME/Injectables referrals, Surgery Procedure referrals)


What are the hours? ( Training hours?) Work hours generally 8:30 am to 5 pm. No weekends. Training is dependent on prior experience, maybe 1 - 2 week. Trying to find persons who already have this skill set and just need to learn our process.
Will you be interviewing (face to face or phone) likely phone screens only, possible face to face if needed
Please confirm the worksite location - Various location dependent on need. Like out float case managers











Resource Type







Non IT Contractor








What Segment will this Contractor(s) Support?







OptumHealth








Is this position for TriCare related work, and if yes, what pay grade equivalency?







No - This position is not TriCare related








If this is Tricare related, does this position require National Agency Check (NAC) clearance?







No








Minimum Education Requirement







Highschool/GED or equivalent










Position involved in functions such as utilization management, medical case management, medical directors, nurseline, pharmacy management, quality management, etc. which require advanced medical training i.e. MD,RN, LPN, etc.
Primary Responsibilities:
• Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines.
• Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria.
• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
• Answers Utilization Management directed telephone calls; managing them in a professional and competent manner
• Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turn around times.
• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member.
• May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses.
• Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department.
• Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies.
• Documents rate negotiation accurately for proper claims adjudication.
• Identify and refer potential cases to Disease Management and Case Management.
• Performs all other related duties as assigned.

Qualifications
To be considered for this position, applicants need to meet the qualifications listed in this posting.
Required Qualifications:
• Current RN license, applicable for practice in the applicable state
• 2 years of experience in managed care OR 5 years of nursing experience as an RN
• Strong problem solving and analytical skills.
• Proficient in PC software computer skills.
• Excellent communication skills both verbal and written skills.
• Ability to interact productively with individuals and with multidisciplinary teams.
• Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills.
Preferred Qualifications:
• Previous Prior Authorization experience
• Utilization Review/Management experience
• ICD-10, CPT coding knowledge/experience
• InterQual or Milliman Knowledge/experience


What are the hours? ( Training hours?) 1 shift 8 AM-5 PM, 1 shift 830 AM-530 PM, 1 shift 9AM-6PM
Will you be interviewing (face to face or phone)both- I can screen over the phone, but would like to meet them face to face for the interview.
Please confirm the worksite location - all postings are for onsite at 5800 Northwest Parkway, San Antonio TX 78249- there is no option to work at home.




Resource Type





Non IT Contractor




What Segment will this Contractor(s) Support?





OptumCare




Is this position for TriCare related work, and if yes, what pay grade equivalency?





No - This position is not TriCare related




If this is Tricare related, does this position require National Agency Check (NAC) clearance?












Dignity Heath Screenings will be need in additional to background check and drug test.

Position Description: The Director, Patient Registration is responsible for supervising monitoring and managing the 24/7 operations of the Patient Registration Department, with the goal of providing superior customer service and obtaining maximum reimbursement for services. The Supervisor will supervise PM shift members of the department. The Patient Registration Department registers all patients for services by collecting, processing and documenting vital information as a service to patients, physicians, nursing, ancillary departments, Patient Financial Services and insurance payers.

Primary Responsibilities:

This position reports to the Regional Director - Patient Registration
Participates in recruitment and selection of new hires, department orientation, training and counseling of staff; in conjunction with the Site Director, completes and processes probationary and scheduled appraisals for individual staff evaluations.
Monitor staff productivity and quality, develop and recommend changes in procedure and work assignments, and review and approve time cards for department personnel
Responsible for interviewing and hiring applicants, evaluating employee performance, providing discipline and counseling staff.
Provides guidance and constructively influences staff morale.

This position requires awareness and understanding of changes in federal and state regulations and the ability to revise procedures and processes accordingly .
Promptly communicating these changes to staff through continual training processes is essential to maintaining high performance and meeting time requirements. Interfacing regularly with other units and departments within the hospital.


Assist in the Quality Improvement activities; assists in implementing and monitoring adherence to policies, procedures, standards, and objectives to provide the maximum level of quality and timely service to internal and external customers.
Works in collaboration with the Department Managers and Directors to develop and implement integrated policies and procedures.
Maintains confidentiality of information deemed confidential and takes steps to assure processes that protect confidentiality.
Perform other duties as assigned.

Communication and Interpersonal Skills:
Relates with others in a positive manner so that maximum job results are produced.
Effectively uses verbal and written communications skills with others.
Provides accurate and helpful information and instructions, treating each person encountered with respect and compassion .
Utilizes appropriate listening skills while checking for understanding.








Resource Type







Non IT Contractor








What Segment will this Contractor(s) Support?







OptumInsight








Is this position for TriCare related work, and if yes, what pay grade equivalency?







No - This position is not TriCare related








If this is Tricare related, does this position require National Agency Check (NAC) clearance?







No








Minimum Education Requirement







Bachelor's Degree






If you are interested please send your resume to Anthony at anthony.williams@adeccona.com or cal me at 925-349-0308










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