Registered Nurse - Utilization Review Responsible for the facilitation of the inpatient Utilization Management process including in-network, out of network, case management and discharge planning as well as assisting the Associate Director of Inpatient Management with UM/QM functions as necessary. Acts as a facility liaison to promote cooperation and efficiency between the IPA and the facility. RESPONSIBILITIES AND FUNCTIONS • Directly performs concurrent review. • Accurately identifies and documents level of care. • Coordinates, facilitates and documents comprehensive discharge planning. o Coordinates in-network services for OON discharges. • Ensures the appropriate utilization of capitated and contracted specialists, providers, facilities, and vendors according to region and risk. • Attends inpatient review rounds and presents cases to medical director(s), health plans and ACMM management staff • Facilitates OON transfers to In-Network facilities. • Works collaboratively with internal and hospital contract staff : o Initiates letter of agreement for OON services in a timely manner. o Provides input for potential contracts. o Identifies and communicates high dollar / high risk cases o Oversees the utilization of contracted facilities and reports OON utilization. • Develops and maintains relationships with both network and Out of Network hospital UM and ER staff. • Works directly with AppleCare Hospitalists to develop and implements inpatient processes including, but not limited to: o Identification of patients and referral to specialty clinics such as Comprehensive Care (high-risk) Clinic, Anti-coagulation and/or Diabetic Clinic. o Facilitates and ensures timely communication between PCP and Hospitalists. • Provides direct Case Management activities if necessary. o Identifies readmit for CM coordinations. o Identifies Healthy Families and Medi-Cal members for CCS referral and facilitates those referrals o Identifies and coordinates high dollar/high risk patients to case management. • Participates in UMC/QIC, PCP, Provider Office Meetings, health plan JOMs, and hospital JOCs as assigned. • Participates in inpatient UM/QM projects and completes in a thorough and timely manner. • Other duties as assigned which may include weeknight, weekend, and holiday on-call. Level of Education: Associates degree in Health Care related field. Professional Certification or License • Active California LVN or RN license • Valid California Drivers license and insurance Level of Experience • Minimum of 5 years experience or above in a Managed Care environment, preferably in an IPA or MSO. Specific Knowledge, Skills, and Abilities • Thorough clinical knowledge of common inpatient diagnoses. • Understanding of DRGs • Strong organizational skills • Ability to perform complex problem soling • Ability to work effectively with physicians • Knowledge of HMO, MSO, and ACO structures and operations. • Strong people skills • Strong Microsoft office Word, Excel and internet skills • Knowledge of standardized CMS, Medicare Advantage, HMO, and Medi-Cal benefits structures. ( Training hours and hours to be filled)

M-F 8 hours a day from 8am – 5pm with a 1 hour lunch.

Training will be from 1-2 weeks

Worksite Location:

18 Centerpointe Drive - LaPalma, CA  90623