Partnership HealthPlan of California
Nurse Coordinator II - LVN
Partnership HealthPlan of California, Fairfield, California, United States, 94533
Utilization Management Services
The incumbent utilizes clinical judgement in providing utilization management services. The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. Assists in determining appropriateness, quality and medical necessity of treatment plans using pre-established guidelines. This position may be assigned cases in long-term or specialty care review. May also carry a caseload of cases requiring telephonic and/or on-site inpatient review at acute or rehab facilities. Responsibilities
Conducts retrospective claims review , either in the aggregate or on an individual basis. Provides summaries of findings to the Team Manager/UM. Evaluates appropriateness of care
through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC and/or CMS regulatory requirements and PHC policies and procedures for each product line. Recommends and coordinates interventions
to facilitate high quality, cost-effective treatment plans, monitoring treatment, progress and outcomes of patients in treatment plan review programs. Screens cases and makes referrals to specialty advisers for review questions and recommendations as needed. Documents and maintains patient-specific utilization management records
in database and files. Assists in the refinement/improvement
of the HS programs. Participates in continuous process improvement endeavors. Works with other PHC departments
to resolve issues relating to authorization of medical services. Audits medical records
as appropriate. Performs inter-rater reliability audits
as directed by department manager. Elicits medical information
from providers and medical records and applies clinical judgement to determine medical necessity and provide timely reports/authorizations for recommended treatment. Refers cases that do not meet criteria
on to the PHC HS department manager, director or Chief Medical Officer as appropriate. Assists in training and orientation
of new staff to the department. Secondary duties and responsibilities: Participates in special projects and assignments
as required. Qualifications
Education and Experience Bachelor's degree in Nursing or RN/LVN license; 3-5 years acute care experience to include one (1) year managed care (utilization or case management) experience; or equivalent combination of education and experience. General knowledge of managed care with emphasis in UM or CM preferred. Special Skills, Licenses and Certifications Current California RN/LVN license. Strong knowledge of nursing requirements in a clinical setting. Knowledge of utilization and case management programs as related criteria and protocols. Familiarity with business practices and protocols with ability to access data and information using automated systems. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines. Strong organizational skills required. Effective telephone and computer data entry skills required. Valid California driver's license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business. Performance Based Competencies Excellent written and verbal communication skills with ability to read and interpret benefit contract specifications. Ability to understand and follow established criteria and protocols used in managed care functions. Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses. Ability to apply clinical judgment to complex medical situations and make quick decisions. Ability to communicate effectively with coworkers, members, their families, physicians, and health care providers. Work Environment And Physical Demands Daily use of telephone and computer for most of the day. Cubicle work station. Ability to use a computer keyboard. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs. All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan's policies and procedures as they may from time to time be updated. HIRING RANGE: $40.94 - $51.18 IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
The incumbent utilizes clinical judgement in providing utilization management services. The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. Assists in determining appropriateness, quality and medical necessity of treatment plans using pre-established guidelines. This position may be assigned cases in long-term or specialty care review. May also carry a caseload of cases requiring telephonic and/or on-site inpatient review at acute or rehab facilities. Responsibilities
Conducts retrospective claims review , either in the aggregate or on an individual basis. Provides summaries of findings to the Team Manager/UM. Evaluates appropriateness of care
through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC and/or CMS regulatory requirements and PHC policies and procedures for each product line. Recommends and coordinates interventions
to facilitate high quality, cost-effective treatment plans, monitoring treatment, progress and outcomes of patients in treatment plan review programs. Screens cases and makes referrals to specialty advisers for review questions and recommendations as needed. Documents and maintains patient-specific utilization management records
in database and files. Assists in the refinement/improvement
of the HS programs. Participates in continuous process improvement endeavors. Works with other PHC departments
to resolve issues relating to authorization of medical services. Audits medical records
as appropriate. Performs inter-rater reliability audits
as directed by department manager. Elicits medical information
from providers and medical records and applies clinical judgement to determine medical necessity and provide timely reports/authorizations for recommended treatment. Refers cases that do not meet criteria
on to the PHC HS department manager, director or Chief Medical Officer as appropriate. Assists in training and orientation
of new staff to the department. Secondary duties and responsibilities: Participates in special projects and assignments
as required. Qualifications
Education and Experience Bachelor's degree in Nursing or RN/LVN license; 3-5 years acute care experience to include one (1) year managed care (utilization or case management) experience; or equivalent combination of education and experience. General knowledge of managed care with emphasis in UM or CM preferred. Special Skills, Licenses and Certifications Current California RN/LVN license. Strong knowledge of nursing requirements in a clinical setting. Knowledge of utilization and case management programs as related criteria and protocols. Familiarity with business practices and protocols with ability to access data and information using automated systems. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines. Strong organizational skills required. Effective telephone and computer data entry skills required. Valid California driver's license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business. Performance Based Competencies Excellent written and verbal communication skills with ability to read and interpret benefit contract specifications. Ability to understand and follow established criteria and protocols used in managed care functions. Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses. Ability to apply clinical judgment to complex medical situations and make quick decisions. Ability to communicate effectively with coworkers, members, their families, physicians, and health care providers. Work Environment And Physical Demands Daily use of telephone and computer for most of the day. Cubicle work station. Ability to use a computer keyboard. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs. All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan's policies and procedures as they may from time to time be updated. HIRING RANGE: $40.94 - $51.18 IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.