UTILIZATION MANAGEMENT INPATIENT REVIEW & CARE TRANSITION NURSE

Location
San Mateo, California
Salary
Competitive
Posted
Dec 07, 2017
Closes
Jan 07, 2018
Contract Type
Permanent
Hours
Full Time

UTILIZATION MANAGEMENT INPATIENT REVIEW & CARE TRANSITION NURSE

The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time UM Inpatient Review & Care Transition Nurse to Ensure that prospective, initial and concurrent reviews for all inpatient and prior authorized admissions are completed within specified timeframes using evidence based criteria for medical appropriateness to support the admission level.  Coordinate clinical needs across the continuum of care by contacting and establishing links with physicians and other providers and community resources.

The following essential duties & responsibilities  will include:

  • Responsible for the proactive management of acutely and chronically ill members, with the objective of improving quality outcomes and decreasing utilization costs. 
  • Beginning with the day of admission, work collaboratively with facility partners to evaluate and provide feedback to admitting physicians and Discharge Planning staff regarding a member's anticipated discharge plans and coordination of covered services.
  • Coordinate an interdisciplinary approach to support continuity of care. 
  • Complete telephonic post discharge assessment and assist members with scheduling appointments for PCP, specialists and transportation services as might be needed.
  • Contact healthcare provider to facilitate notification of admission and to any changes to members individual care plan as a result of the Care Transition.
  • Complete all required documentation and telephonic member follow-up within specified computer systems and within the required timeframes.
  • Responsible for the early identification and assessment of members for potential inclusion in a comprehensive case management program.  Refer members for Case Management accordingly.
  • Reconcile daily hospital census reports and face sheets against authorizations.
  • Perform other duties as assigned.

Requirements

Education and Experience equivalent to:

  • Bachelor’s degree in nursing preferred.
  • Two years relative clinical nursing experience.

License: Valid and unrestricted California license as a Registered Nurse or LVN.

Certification: Certification as Certified Case Manager (CCM) preferred.

Knowledge of:

  • Case management principles and practices.  
  • Managed Care processes, including use of Milliman Care guidelines or InterQual.
  • Working knowledge of all relevant federal, state, local and regulatory requirements.
  • Community resources.
  • Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.

Ability to:

  • Work efficiently with people in varying positions.
  • Work independently, with limited supervision; problem solve independently.
  • Provide excellent customer service. Effectively communicate both verbally and in writing. Utilize personal computers and Microsoft Office products (Word, Excel, Access and Outlook). 

Starting Compensation Range: $73, 825 - $105, 570/annually- depending on experience.

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s coverage in the medical HMO plan and majority of PPO medical cost.  Employee pays a small portion of the dependent premiums for medical and dental benefits.  Additional HPSM benefits include fully paid vision, life, AD&D, STD, and LTD insurance; retirement plan (10% of salary for compensation/HPSM paid); holiday and vacation pay; tuition reimbursement plan; and more.

Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: careers@hpsm.org or via fax: (650) 616-8039. File by: Continuous until filled.  EOE

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