Utilization Management Case Manager II (Per Diem, Day)

NorthBay Health•Fairfield, CA

18h•$78 - $90

About The Position

At NorthBay Healthcare, Utilization Management (UM) is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes. UM Case Managers work under the direction of the Manager of UM and the AVP of Care Coordination. They collaborate across the continuum of the system with patients, physicians, staff, broker services, and administration to ensure appropriate care at the appropriate level for high-risk members. The UM Case Manager utilizes clinical knowledge, positive communication skills, problem-solving and conflict resolution techniques, the ability to effect change, and strong skills in assessment, organization, and time management. The UM process requires a focus on critical thinking, customer service, setting appropriate goals, and measuring outcomes to effectively ensure optimal patient outcomes with consideration to financial and health plan resources. The UM Case Manager at NorthBay Healthcare must demonstrate adherence to department and system policies, procedures, quality assurance, guidelines, and goals of the department and the organization.

Requirements

Clinical knowledge and competence
Positive communication skills
Problem solving and conflict resolution techniques
Ability to effect change
Strong skills in assessment, organization, and time management
Critical thinking skills
Customer service skills
Ability to set appropriate goals and measure outcomes
Adherence to department and system policies, procedures, quality assurance, guidelines and goals

Responsibilities

Works across the continuum of ambulatory, hospital and ancillary services to coordinate care for the patient at the appropriate level.
Serves as liaison with the Health Plans.
Authorizes and monitors internal, external and out-of-area admissions and services.
Identifies high-risk patients utilizing health risk assessment tools, referral forms and Midas reports.
Coordinates care of patient with the physician, clinical/hospital staff and family members to ensure utilization of the appropriate level of care.
Serves as resource for physicians and staff on matters concerning Health Plan benefits, restrictions and limitations.
Assesses the needs of capitated members for durable medical equipment, home health, and skilled nursing placement and authorizes appropriately.
Works with the capitated Health Plan to repatriate member back into the NorthBay Healthcare System when appropriate.
Applies NorthBay Healthcare System approved UM decision criteria to the management of complex and chronic cases.
Assesses, plans, implements, coordinates and evaluates individualized treatment plans for the case managed patient.
Applies benefits appropriately. Authorizes exceptions to benefits on a case by case basis when in the best interest of the patient and the System.
Coordinates care with Medical Group UM department.
Notifies appropriate personnel of out-of-area admission in a timely manner.
Complies with NorthBay Hospital approved time frames and standards for timeliness of UM decision-making.
Identifies and refers members to Health Plan who meet the Health Plan’s criteria for evaluation for special financial status.
Other duties as assigned.