Facilitates cost effective care throughout the continuum utilizing a collaborative multi-disciplinary approach. Implements the nursing process including assessment, planning, implementing, coordinating, monitoring and evaluating options and services for patients and families experiencing complex/catastrophic illnesses. Responsible for the assurance of quality medical management and cost containment in the Utilization (Medical) Management department in the PMG/IPA. This includes, but is not limited to: utilization and referral management and total case management, in both the inpatient and outpatient settings.


RESPONSIBILITIES AND FUNCTIONS
• Daily onsite patient visits, reviewing of all medical records, admission review
• Discharge planning with collaboration of skilled nursing facility staff, attending SNF physician, patient and or family representative.
• Participates in weekly IPA SNF rounds providing a concise history and overview of the member’s progress and discharge plan.
• Assures NOMNC process if followed per CMS regulations (issuing of, presenting, and receipt of completed compliant form).
• Communicates discharges daily to UM Tech and UM Manager.
• Reviews SNF cases with UM Manager as needed to resolve complex discharge issues and barriers as needed.
• Documents MCG Guideline(s) on every inpatient case within 24 hours of admission notification and updates guideline as stay continues.
• Notifies patient’s Primary Care Physician of admission, discharge and discharge plan within 24 hours of each event as appropriate per NE process.
• Analyzes medical cases for appropriateness and plans and coordinates all phases of care in conjunction with the Skilled nursing facility, attending SNF’ist, specialists in the outpatient settings.
• Collaborates with physicians, patients, and families to formulate an optimal plan of care that meets all of the medical, psychosocial and financial needs of the patient
• Explores care options to reduce cost, decrease length of stay, prevent re-admission and influence quality outcomes.
• Understands capitation vs. fee for service.
• Knowledgeable regarding network providers and current contracted specialists,
manages cases according to delegation agreement requirements, including notifications regarding LOS.
• Understands health plan benefits and contractual information
• Generates authorizations utilizing principles of UM
• Accurately uses database for daily documentation of clinical information, opportunity days, denied days and levels of care.
• Follows policy and procedure for Denials and enters this information into the database with 24 hours of the event.
• Assists with implementation of all policies and procedures in the group through knowledge and experience.
• Assists in training/crosstraining of staff, in conjunction with corporate department, to maximize effectiveness and utilize staff to their fullest potential.
• Meets all health plan contract compliance directives for utilization.
• Maintains ongoing communication and feedback with customers and/or clients in order to support needs and resolve problems.
• Manages error reports on a routine basis
• Identifies and refers members to Case Management prior to discharge or as deemed appropriate through referral review
• Participates in weekly IPA SNF rounds providing a concise history and overview of the member’s progress and discharge plan.
• Attends onsite facility ICT as appropriate.
• Other duties as assigned.
• Regularly communicates with Health Plans as appropriate.
Level of Education (specify level and major; Example: B.S. in Chemistry) indicate level and description.
AA, Bachelor’s Degree, or equivalent from four year college or technical school.
Professional Certification or License (Example: CPA, CPP, none)
RN or LVN with current California license.
Level of Experience (specify type and length; Example: 1-2 years supervisory experience)
2 plus years clinical experience in acute care (i.e., ICU, CCU, ER, med-surg) or related health care experience.
1 year managed care experience

Specific Knowledge, Skills, and Abilities (Example: Familiarity with spreadsheet applications such as Excel and/or Access.
• Strong ability to work effectively with physicians and ancillary staff, both written and verbally.
• Ability to perform complex problem solving related to health care utilization.
• Self motivated with strong quantitative and organizational skills.
• Knowledge of general PMG/IPA operations.
• Flexible and adaptable of schedule to attend various meetings and/or promotional events.
• Ability to read quickly with excellent comprehension and retention.
• Computer literate in Microsoft Word
• Participates in a team environment supporting and respecting all members, encouraging achievement of group goals.
• Able to problem solve and make decisions independently.
• Ability to manager competing priorities and work under significant time constraints.
• Ability to synthesize large volumes of information.