RN, Care Manager, Utilization Management (Part Time, Every Weekend)

Adventist Health•Roseville, CA

15d

About The Position

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. Job Summary: Plays a critical role in ensuring that patients receive high-quality care while efficiently utilizing medical resources. Reviews patient medical records, assessing the appropriateness and necessity of proposed treatments, and collaborating with healthcare providers and insurance companies to ensure a seamless care experience and the practicing of financial stewardship and denial prevention. Focuses on maximizing patient outcomes and optimizing resource allocation. Utilizes exceptional clinical knowledge, excellent communication skills, and the ability to thrive in a fast-paced and ever-changing healthcare environment.

Requirements

Associate’s Degree in nursing or equivalent combination of education/related experience: Required
Five years' acute hospital experience required with preferred experience in critical care areas: Required
Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months: Required
Registered Nurse (RN) licensure in the state of practice: Required

Nice To Haves

Bachelor's Degree in Nursing (BSN): Preferred

Responsibilities

Completes clinical reviews of acute medical patients using the Optum/Inter Qual tool to determine if the patient is in the right acute setting, receiving the right acute services, during the appropriate length of stay.
Participates in annual Optum/Inter Qual training required.
Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score as defined in the yearly departmental goals.
Meets weekly productivity metrics within 90 days of completing orientation and maintains on a weekly basis as defined in the yearly departmental goals.
Meets quality audit metrics within 90 days of completing orientation and maintained on the audit cadence set within the department as defined in the yearly departmental goals.
Completes all required departmental education assigned with timeliness and accuracy.
Follows all departmental workflows in communication variances to the on-site care management teams when appropriate.
Reviews and analyzes medical records to assess the necessity and appropriateness of treatments and interventions.
Collaborates with healthcare professionals to develop and implement comprehensive patient care plans.
Facilitates communication between the patient, healthcare team, insurance providers, and other stakeholders to ensure a coordinated and efficient care process.
Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices to ensure the delivery of optimal healthcare services.
Performs other job-related duties as assigned.