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Providence Health & Services Utilization Review Nurse Case Manager in Mission Hills, California

Description:

Providence is calling a Utilization Review (UR) Nurse Case Manager (Per diem/Day shift) to Providence Facey Medical Foundation, Mission Hills CA.

We are seeking a Utilization Review (UR) Nurse (RN) Case Manager who will be responsible for utilization review and discharge planning for capitated patients who are hospitalized. The review includes coordination of services for medical necessity, cost effectiveness, timelines of service and ensuring that quality standards are met. Performs coordination of services for patients whose health plan has an at-risk agreement to ensure that services are medically necessary, cost effective, provided in a timely manner and meet local standards or care.

In this position you will have the following responsibilities:

  • Act as a resource for case management activities:

  • Deliver upon the service expectations of both our patients and fellow staff members by listening to their needs; engaging in positive interactions; and following through on promises made in a thoughtful, efficient, timely and courteous manner so that their total outcome is better than expected

  • Respect the dignity, confidentiality and privacy of patients

  • Work in a safe manner, adhering to general safety precautions and standards. Reports any unsafe conditions to their supervisor and/or the safety hotline

  • Perform concurrent review on hospitalized patients at Henry Mayo Hospital, Holy Cross Medical Center, Northridge Hospital Medical Center, San Gabriel Valley Medical Center, Valley Presbyterian and Skilled Nursing Facilities. Works collaboratively with the hospital based physician

  • Refer cases not meeting Facey Medical Group criteria for hospitalization to physician advisor/medical director. Advises appropriate medical group or insurer when acute care is no longer required so that denial letters may be issued

  • Reviews hospitalized patients with the Medical Director and/or UR chairperson as requested

  • Assist with review and processing of the UR requests

  • Attend weekly UR meetings and other meetings as indicated

  • Maintain records and statistics as required, i.e. - bed days, discharges, re-admissions, diagnoses

  • Coordinate transfer of “out-of-area” patients into network hospitals, when indicated

  • Refer cases to California Children Services as appropriate for additional coverage and services

  • Rotate on-call by beeper coverage for telephone assistance to physician regarding Utilization Management issues

  • Maintain confidentiality of all patient and Utilization Management information

  • Perform Discharge Planning/Case Management activities:

  • Perform concurrent review of hospitalized patients and formulates discharge plan/case management within two working days of admission

  • Implement discharge plan/case management and makes appropriate referrals to Home Health Agencies, Skilled Nursing Facilities, Board and Care Facilities, Hospice Care, etc. Works closely with the discharge planners at Henry Mayo Hospital, Holy Cross Medical Center, Northridge Hospital Medical Center, San Gabriel Valley Medical Center, Valley Presbyterian and/or appropriate hospital to facilitate timely transfer or discharge

  • Arrange placement of patients in facilities that are appropriate for their level of care requirements

  • Authorize Skilled Nursing Facilities, durable medical equipment and home health care when medically necessary, included in the patients’ health plan benefits

  • Make regular visits to contracted Skilled Nursing Facilities to ensure that services provided are medically necessary and meet the community standards of care

  • Refer appropriate cases to Social Services for psycho-social intervention. Refers appropriate cases for Medi-Cal and California Children Services and/or agencies

  • Maintain accurate and thorough documentation of discharge planning/case management activities on the patient’s medical record as well as Utilization Management worksheets

  • Work collaboratively with other members of the health care team as well as the respective medical groups to facilitate the Utilization Management process

  • Identify and refers situations needing immediate intervention to UR Manager, UR Medical Director, Quality Assurance and Risk Management, as appropriate

  • Participate in UR Department and Quality Assurance program and projects as needed

  • Maintain a log and report of all catastrophic cases

  • Enter all re-admissions into the computer by diagnosis and maintains a log of telephone case management on these patients

  • Follow-up on discharged patients by telephone as necessary to ensure delivery of medical equipment, home health visits and assesses how they are doing

  • Maintain a high degree of professionalism:

  • Demonstrate the ability to make decisions, take appropriate action and follow tasks through to completion

  • Recognize and analyze the implications of new situations and develops workable solutions to maintain productivity and morale.

  • Act as a role model in demonstrating the customer service standards of the organization

  • Demonstrate a commitment to personal growth and development by participating in external activities related to professional goals

  • Respond cooperatively to managers and staff members in other departments to promote teamwork

  • Attend departmental meetings as appropriate and contributes ideas for improving efficiency, productivity and patient satisfaction

Qualifications:

Required qualifications for this position include:

  • RNgraduateofanaccredited Schoolof Nursing

  • Current California Registered Nurse License

  • AmericanHeartAssociationBLSforHealthCare Providers

  • Strong clinical background preferably in acute care or home health

  • Mustpossess excellent customer serviceandcommunication skills

  • Mustbeorganizedandaself-starter,beabletoutilize multiple resourcestodeterminehealthplanrequirementsandbenefitsasappliedtotheutilizationandcase management process andclinicaldecisionmaking

  • Must haveworking understanding of MSOutlook, Word and Excelandbecapableofbeingtrainedinreferralprocessingsoftware

Preferred qualifications for this position include:

  • Bachelor's Degree

  • Minimum of three (3) years experiencepreferredinamanagedcaresetting/utilizationreview/discharge planning/casemanagement

About the organization you will serve:

Facey is a Medical Group with offices in the San Fernando, Santa Clarita, Simi and San Gabriel Valleys. We are known as a multi specialty medical group, meaning we employ over 180 healthcare providers offering a broad range of specialties including primary care, OB/GYN and medical and surgical specialties. Facey operates two Urgent Care Centers (Santa Clarita & Mission Hills) that offer comprehensive physician services, lab and radiology seven days a week. We have affiliations with several hospitals in our service areas including Providence Holy Cross Medical Center, Providence St. Joseph Medical Center, Henry Mayo Newhall Medical Center, Northridge Medical Center, Simi Valley Medical Center and San Gabriel Medical Center. We are physicians who treat members of various insurance plans. Facey contracts with most of the major health insurance plans. We see HMO, PPO, Medicare, MediCal and cash pay patients. For those who are Medicare eligible, Facey not only takes Medicare but we contract with many of the Medicare Advantage Prescription Drug Plans (MAPD – HMO) as well as Medicare Supplement or MediGap PlansHigh School

We offer a full comprehensive range of benefits - see our website for details

http://www.providenceiscalling.jobs/rewards-benefits/

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence Health & Services is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and services guided by a Mission of caring the Sisters of Providence began over 160 years ago. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: On Call

Shift: Day

Job Category: Case Management

Location: California-Mission Hills

Req ID: 255611

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