RN Case Manager and Utilization Review Opportunity in Torrance

In search of a RN with Case Management exp. AND a RN with Utilization Review exp.

These are full-time Healthcare opportunities within a leading organization.

Case Manager
Job Responsibilities:
In this role you will be responsible for utilization review and ensuring the continuity of care for all patients admitted to skilled nursing facilities or acute care hospitals by coordinating in-facility service, discharge arrangements, and transition to the outpatient setting, assuring that services are provided within the parameters of established contracts and the patient's health plan benefits. This management is either performed on-site or by telephone, and is done under the supervision of the Manager, Care Management. Also performs other duties as delegated by the Manager, Care Management.

Utilization Review
Job Responsibilities:
Responsible for educating the individual CM regional departments on the regulatory requirements from all regulatory organizations (CMS, NCQA, and contracted Health Plans), and for assisting regions in maintaining regulatory compliance of Care Management processes. Acts as a resource in the areas of referral processing, denial letter processing, and clinical decision making.
Conducts regional-based training to educate Care Management staff on health plan regulatory procedures and processes.
Acts as a central resource with regards to regulatory requirements from participating regulatory agencies as well as health plan clinical review criteria and HMO benefits.
Contributes pertinent Utilization-related materials to the departmental Sharepoint site.
Assists in preparing the department for annual health plan audits.
Conducts review of procedures related to referral processing, including oversight of denial letter processing.
Performs reviews as needed on other related Care Management processes including but not limited to retrospective review of referral, prospective review of referrals, and appeals review.
Demonstrates a thorough understanding of the cost consequences resulting from Care Management decisions through utilization of appropriate reports: Health Plan Eligibility and benefits and Division of Responsibility (DOR).
Communicates authorization/denial for services to appropriate parties. Communication may include patient (or agent), attending/referring physician, facility administration, and HCP claims department as necessary.
Participates, as requested, in assigned Care Management Committee meetings. Addresses pertinent regulatory information to all members of the health team when appropriate.
Contributes to current Care Management programs within the policies and procedures set by the Care Management Department
Contributes to team decisions in the development of enhancements to the electronic referral management system.
Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients, and families.
Initiates and/or oversees data entry into IS systems within parameters of Care Management policies and procedures. Maintains accurate and complete documentation of services requested including CPT code, ICD 9, referral type, date, and etc.
Assumes other Care Management duties as delegated.
REQUIREMENTS
Case Manager
Requirements:
Current CA RN liscensure. A bachelors degree from a four-year college and/or a professional certification requiring formal education beyond a two year college. 3 - 5 years experience. Graduation from an accredited school of nursing. Knowledge of medical/nursing standards of care. Strong writing skills are essential to the success in this position. Ability to effectively communicate and collaborate with physicians, patients, families, and ancillary staff. Able to make sound, independent judgments, and act professionally under pressure.



Utilization Review
Requirements:
Current CA RN liscensure
At least one year of recent clinical experience.
Graduation from an accredited school of nursing.
Knowledge of current standards of patient care and thorough understanding of RN scope of practice.
Ability to effectively communicate and collaborate with physicians, patients, families, and ancillary staff.
Able to make sound, independent judgments, and act professionally under pressure.
Computer proficiency