Clinical Intake Coordinator RN I - Temporary

KHS•Bakersfield, CA

4d•Onsite

About The Position

This is a full-time temporary position where the RN Clinical Intake Coordinator is responsible for supporting the clinical Utilization Management activities for KHS members. The role involves conducting medical necessity reviews of referral requests for services such as DME, outpatient therapies, and prior authorizations for outpatient procedures and prospective inpatient stays. The coordinator will utilize Milliman Care Guidelines and Medi-cal criteria for decision-making and refer cases to the KHS Medical Director when criteria are not met. This role also serves as a clinical resource for Non-Clinical Intake Coordinators, providing expertise on criteria, benefits interpretation, and clinical guidance.

Requirements

Registered Nurse (RN) with an active, current, unrestricted CA license.
Minimum of two years (2) full-time clinical experience in acute care, community health setting, public health nursing or chronic disease management required.

Nice To Haves

Experience with MCG Health LLC clinical guidelines and Medi-CAL coverage preferred.
Experience working in case management or care coordination is a plus.
Knowledge of Kern County Community resources for seniors and people with disabilities is a plus.

Responsibilities

Performs review of requested outpatient and elective, prospective inpatient medical services.
Under the direction of the UM Outpatient Clinical Supervisor coordinates and refers KHS members for services which are carved out of KHS medical coverage.
Assists in the authorization and processing of automatic referral requests.
Responsible for written and verbal communication with contract providers and internal KHS staff to promote timely coordination of care and dissemination of KHS policies and procedures.
Collaborates with the KHS Member Service Department and the Provider Relations Department regarding quality of care and other grievance issues to facilitate timely problem resolutions.
Utilizes clinical guidelines as well as Medi-Cal criteria to review DME, home care, and outpatient service requests for medical necessity and benefit coverage while processing referral request.
Identifies and refers cases for quality of care, coordination of benefits, and third-party liability issues as appropriate.
Maintains knowledge of covered benefits for all programs.
Identifies and refers cases appropriate for various internal programs. Shares information as necessary with appropriate Population Health Management team: Case Management, Transitions of Care, Major Organ Transplant and Community Support Services including but not limited to Extended Care Management.
Identifies authorization issues and brings those requiring attention to the UM Outpatient Clinical Supervisor.
Reviews requests for non-par services and coordinates these with input from the Medical Director based on par provider availability in the member’s geographic area.
Selects, formats, proofreads and prints appropriate member and provider denial letters prior to mailing.
Determines medical appropriateness and necessity of care using established criteria within mandated turnaround times.
Appropriately refers cases that do not meet medical necessity to the Medical Director.
Keeps current with California Children’s Services benefits and guidelines for coordination of services.
Other duties as determined based on Department needs.