Care Management Utilization Management RN Coordinator - Alameda Health System : Job Details

Summary

SUMMARY: Manages the utilization of the AHS designated patient population including, but not limited to, care coordination and medical determination for Outside Medical Services functions and managing the referral network.DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Assists in the development, modification, and delivery of care guidelines standards and procedures to meet regulatory and organizational guidelines.

2. Collaborates and communicates as necessary with AHS and non AHS physician offices, patients, contracted ancillary vendors, sponsoring organizations (i.e. Department of Managed Health Care, Alameda County Health department, California Children's Services), internal departments and any other providers when appropriate.

3. Collaborates with Contracting to develop and maintain a contracted referral network; seeks rendering providers and services; manages the RFP process.

4. Collaborates with reporting team to obtain and monitor productivity, utilization and financial costs (e.g. turnaround times, timeliness follow up, total costs of care, access to care, volume of service requests).

5. Collaborates with Revenue Cycle to ensure patient eligibility and billing is accurate and complete.

6. Educate providers on utilization and medical management processes.

7. Evaluates medical necessity for healthcare services with evidence-based criteria and guidelines

8. Generates required correspondence/review notification to patients and providers of authorization determination.

9. Informs and advises medical providers of patients' clinical status and maintains open communication with AHS providers and clinical staff to ensure timely notification of any health conditions or diagnosis that could qualify patient for programs and services to assist them with their healthcare costs.

10. Performs other duties as assigned.

11. Provide clinical knowledge and act as a clinical resource to non-clinical team staff.

12. Represents AHS's objectives and goals for managing a specific AHS designated patient population

13. Responsible for clinical review of authorizations includes but not limited to ambulatory and inpatient services requests as outlined by AHS contractual arrangements with payers.

14. Responsible for monitoring of an AHS specific patient population utilization which includes outpatient services within AHS and externally as well as inpatient utilization.

15. Responsible for timely incoming and outbound clinical requests, questions, concerns, and complaints.

16. Reviews with contracted vendors' access to care, quality and volume; escalates any patient safety or financial discrepancies.

17. Serves as content expert for utilization management process, benefit interpretation and reporting; fosters relationships with payors and medical groups to process authorization requests.

18. Takes appropriate action when requests do not meet criteria or are denied or not a covered benefit. Assists with the interpretation of the contract for patient population. Notifies and coordinates the referring physician. Works with Director, Care Management to review request if appropriate.MINIMUM QUALIFICATIONS:

Required Education: Bachelor's of Nursing

Preferred Education: Master's in Nursing

Required Experience: Three years of acute care nursing; recent experience in Case Management or utilization review in an acute setting or a medical group or health plan.

Preferred Experience: Broad clinical background; medical/surgical or critical care

Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California; active BLS - Basic Life Support Certification issued by the American Heart Association.

Preferred Licenses/Certifications: Certification in Case Management, CCMC, CPUR or ACM.Highland General HospitalSYS Utilization ManagementFull TimeDayCare ManagementFTE: 1