Nurse Coordinator I - RN

Partnership HealthPlan of California•Redding, CA

3d•$50 - $64

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.
Excellent written and verbal communication skills with ability to read and interpret benefit contract specifications.
Ability to understand and follow established criteria and protocols used in managed care functions.
Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses.
Ability to apply clinical judgment to complex medical situations and make quick decisions.
Ability to communicate effectively with coworkers, members, their families, physicians, and health care providers.

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 PHC 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 PHC 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 PHC HS department manager, director or Chief Medical Officer as appropriate.
Participates in special projects and assignments as required.