Job Description
Position Overview:
We are seeking a compassionate and detail-oriented healthcare professional to join our team. In this role, you will work closely with members, providers, and multidisciplinary team members to assess, facilitate, plan, and coordinate integrated care across a wide range of healthcare services. Your focus will be on ensuring members with high care needs receive the appropriate behavioral health and long-term care services, ensuring that care is medically appropriate, effective, and delivered in a cost-efficient manner.
Key Responsibilities:
Inpatient Services Review: Assess inpatient services to ensure optimal outcomes and cost-effectiveness, while adhering to state and federal regulations and guidelines.
Clinical Service Review: Analyze clinical service requests against evidence-based guidelines to ensure the most appropriate care is being requested for members.
Benefits and Eligibility: Identify the right benefits, eligibility, and expected length of stay for requested treatments and procedures.
Financial Responsibility Determination: Conduct inpatient reviews to assess the financial responsibility of healthcare services for both the organization and its members. Assist with prior authorization reviews as needed.
Timely Processing: Ensure that all service requests and reviews are processed within required timelines.
Collaboration with Medical Directors: Refer cases to Medical Directors, presenting them efficiently and effectively for review.
Information Gathering: Request additional information from members or providers when necessary, in a clear and efficient manner.
Clinical Program Referrals: Make appropriate referrals to other clinical programs to ensure comprehensive care.
Team Collaboration: Work closely with multidisciplinary teams to support and enhance our care model.
Policy Adherence: Follow all Utilization Management (UM) policies and procedures to ensure consistency and compliance.
Daily Responsibilities:
Clearing discharges using UMK2 and EMR systems
Managing admission and continued stay reviews for members
Processing NON-PAR and eligibility reviews
Conducting reviews per specific hospital processes (Sharp/SCRIPPS/DIGNITY)
Handling internal reconsideration and peer-to-peer follow-up reviews
Managing denial processes and communicating with providers for additional documentation
Reviewing the Department of Financial Responsibility (DOFR) for financial responsibility assessments
Completing disenrollment tasks for members whose coverage expires
Following hospital assignment grids and MD coverage list requirements
Qualifications:
Required Experience: At least 1 year of experience in a Med-Surg setting is required.
Required Licensure: Active California RN or LVN license is required.
We offer a supportive and collaborative environment where you will play an integral role in ensuring that members receive the highest quality care possible. If you're looking for a role where you can make a real difference in the lives of others, we'd love to hear from you.
Employment Type: Full-Time
Salary: $ 40.00 43.00 Per Hour
Job Tags
Hourly pay, Full time,