Nurse Coordinator I - RN

Partnership HealthPlan of California • Fairfield, CA

3d • $50 - $64 • Onsite

About The Position

The incumbent utilizes clinical judgement in providing utilization management services. The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. Assists in determining appropriateness, quality and medical necessity of treatment plans using pre-established guidelines. This position may be assigned cases in long-term care and ancillary, DME or medical services.

Requirements

• RN/LVN with 2-3 years experience to include one (1) year managed care (utilization management) experience; or equivalent combination of education and experience.
• Current California RN/LVN license.
• Strong knowledge of nursing requirements in a clinical setting.
• Knowledge of utilization management programs as related to use of pre-set criteria and protocols.
• Familiarity with business practices and protocols with ability to access data and information using automated systems.
• Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines.
• Strong organizational skills required.
• Effective telephone and computer data entry skills required.
• Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

Nice To Haves

• General knowledge of managed care with emphasis in UM preferred.

Responsibilities

• Conducts retrospective claims review, either in the aggregate or on an individual basis. Provides summaries of findings to the Team Manager UM.
• Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC and/or CMS regulatory requirements and Partnership policies and procedures for each product line.
• Recommends and coordinates interventions to facilitate high quality, cost-effective care, monitoring treatment, progress and outcomes of patients.
• Documents and maintains patient-specific utilization management records in database and files.
• Assists in the refinement/improvement of the HS programs. Participates in continuous process improvement endeavors.
• Works with other Partnership departments to resolve issues relating to authorization of medical services.
• Audits medical records as appropriate.
• Performs inter-rater reliability audits as directed by department manager.
• Elicits medical information from providers and medical records and applies clinical judgement to determine medical necessity and provide timely reports/authorizations for recommended treatment.
• Refers cases that do not meet criteria on to the Partnership HS department manager, director or Chief Medical Officer as appropriate.
• Participates in special projects and assignments as required.

Benefits

• Provide the highest possible level of service to clients
• Promote teamwork and cooperative effort among employees
• Maintain safe practices
• Abide by the HealthPlan’s policies and procedures as they may from time to time be updated.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree