RESPONSIBILITIES AND FUNCTIONS Directly performs concurrent review. Accurately identifies and documents level of care. Coordinates, facilitates and documents comprehensive discharge planning. o Coordinates in-network services for OON discharges. Ensures the appropriate utilization of capitated and contracted specialists, providers, facilities, and vendors according to region and risk. Attends inpatient review rounds and presents cases to medical director(s), health plans and ACMM management staff Facilitates OON transfers to In-Network facilities. Works collaboratively with internal and hospital contract staff : o Initiates letter of agreement for OON services in a timely manner. o Provides input for potential contracts. o Identifies and communicates high dollar / high risk cases o Oversees the utilization of contracted facilities and reports OON utilization. Develops and maintains relationships with both network and Out of Network hospital UM and ER staff. Works directly with AppleCare Hospitalists to develop and implements inpatient processes including, but not limited to: o Identification of patients and referral to specialty clinics such as Comprehensive Care (high-risk) Clinic, Anti-coagulation and/or Diabetic Clinic. o Facilitates and ensures timely communication between PCP and Hospitalists. Provides direct Case Management activities if necessary. o Identifies readmit for CM coordination's. o Identifies Healthy Families and Medi-Cal members for CCS referral and facilitates those referrals o Identifies and coordinates high dollar/high risk patients to case management. Participates in UMC/QIC, PCP, Provider Office Meetings, health plan JOMs, and hospital JOCs as assigned. Participates in inpatient UM/QM projects and completes in a thorough and timely manner. Other duties as assigned which may include weeknight, weekend, and holiday on-call.
Level of Education: Associates degree in Health Care related field.
Professional Certification or License Active California LVN or RN license Valid California Driver's license and insurance Level of Experience Minimum of 5 years' experience or above in a Managed Care environment, preferably in an IPA or MSO.
Specific Knowledge, Skills, and Abilities Thorough clinical knowledge of common inpatient diagnoses. Understanding of DRGs Strong organizational skills Ability to perform complex problem solving Ability to work effectively with physicians Knowledge of HMO, MSO, and ACO structures and operations. Strong people skills Strong Microsoft office Word, Excel and internet skills Knowledge of standardized CMS, Medicare Advantage, HMO, and Medi-Cal benefits structures.
* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.