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Employment Type : Full-Time
Procare MSO, Inc. is a Management Services Organization that manages IPAs (Independent Physician Associations) in California. We currently manage IPAs with Medicaid HMO and Medicare HMO Members. We're seeking a Utilization Management Coordinator to join our team. RNs and LVNs are welcome to apply. Job Responsibilities: - Performs prospective, initial, concurrent and retrospective reviews for all requested services to include but not limited to the following: inpatient admissions, facility requests, durable medical equipment (DME) and outpatient and home health services - Conducts Pre-certification of all elective admissions with the Health Plan or other certifying entity. - Receives notification of admissions and maintains admission logs. - Monitors level and quality of care of services being provided and approved. - Evaluates and provides feedback as needed to treating physicians regarding a member's discharge and home care plans and available covered services including identifying alternative levels of care that may be covered - Coordinates an interdisciplinary approach to support continuity of care. Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for members - Actively participates in the discussion and notification processes that result from the clinical utilization reviews with facilities and service provider - Maintains compliance with all Health Plan guidelines on the reporting of cases/surgeries. - Understands Health Plan policies and procedures regarding pre-certification, benefits by health plan and preferred facilities within each plan. - Performs inpatient utilization review and applies client guidelines as detailed in the client UM Plan for length of stay/admission criteria to approve initial and continued inpatient services including the application of MCG Clinical Criteria or other Clinical Criteria. - Requests relevant clinical information and documents in operating system. - Prepares and send Admission Notifications and Admission Certifications to Physicians and Hospitals. - Determines level of care and place of service indicated based on medical information available. - Facilitates transition of care /discharge planning of members. - Arranges needed post discharge services such as; DME, Home Health, Skilled Nursing - Coordinate complicated medical cases and retrospective requests with Medical Directors. - Assist referral coordinators in medical determinations on referrals. - Responsible for the early identification and assessment of members for potential inclusion in a comprehensive care coordination program. Refers members for care coordination accordingly - Performs other related activities as assigned. Qualifications: - Licensed Registered Nurse or Licensed Vocational Nurse with active California License - Experience in the application of evidence-based guidelines, such as MCG criteria (formerly Milliman Care Guidelines) and Medicare (CMS) Guidelines. - 1-2 years utilization review and/or managed care experience preferred - Strong computer skills in Microsoft Office Suite - Strong communication and interpersonal skills -Ability to effectively present medical information one-on-one and to small groups - Great if you can speak another language too, like Spanish or Vietnamese. Job Type: Full-time Pay: $19.00 - $30.00 per hour Benefits: Schedule: License/Certification: Work Location: Benefit Conditions: Work Remotely:
Related keywords: utilization review nurse, registered nurse, rn, utilization review, nurse