Provides assistance with oversight during the daily operations of the outpatient review process. Participates in the training and mentoring of team members. Provides support, resources, and direction to staff. Assists in determining appropriateness, quality, and medical necessity of requested service.
Essential Duties and Responsibilities Oversees daily operation of the outpatient review process. Provides direction and support, to staff concerning daily assignments. Provides training in outpatient review to new hires. Provides performance feedback to the UM Team Manager. Participates in the interview process of new hires. Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC CMS regulatory requirements, using PHC policies and procedures, and InterQual criteria for each product line. Documents and maintains patient-specific records in the appropriate data collection software system. Assists in the refinement/improvement of the Health Services programs. Participates in continuous process improvement endeavors. Works with other PHC departments to resolve issues relating to authorization of medical services. Participates in Inter-rater Reliability studies, reviewing medical records as assigned. This position, in addition to their own case load, may require other review responsibilities as deemed necessary to provide coverage. Communicates regularly with the UM Team Manager and works collaboratively to resolve issues. Seeks UM Team Manager assistance as needed while coordinating work, making decisions, and handling questions or problems. Participates in special projects and assignments as required.
Education and Experience
Licensed Vocational Nurse (LVN) or Registered Nurse (RN), with two (2) years of managed care (case management) experience; or equivalent combination of education and experience. General knowledge of managed care with emphasis in utilization and/or case management preferred.
Special Skills, Licenses and Certifications
Current California Licensed Vocational Nurse (LVN) or Registered Nurse (RN), 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.
Performance Based Competencies
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 judgment to complex medical situations and make quick decisions. Ability to communicate effectively with coworkers, members, their families, physicians, and health care providers.
Work Environment And Physical Demands
Ability to prioritize workload and function effectively with frequent interruptions and direction from multiple team members. More than 50% of work time is spent in front of a computer monitor. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs.
All HealthPlan employees are expected to:
HIRING RANGE:
LVN: $49.54 - $64.41
RN: $56.98 - $74.07
IMPORTANT DISCLAIMER NOTICE:
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
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