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RN or LVN Utilization Manager - 31688-1
50 Beale Street San Francisco, California 94105 | Contract
ABOUT THE POSITION:
- Working with complex cases promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits.
- Works with other members of HCS team, provider, hospitals, IPA/MGs, members and their families to plan and review medical necessity, intensity of services, level of care, length of stay and general appropriateness of care.
- Provides guidance to the provider network. Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care.
- May provide case management to member segments with chronic or catastrophic illness.
- Specific licensing requirements may apply depending upon position i.e. LVN, RN or Clinical Social Worker.
- Discharge planning for cases that exceed EOA or dx assigned to RN.
- Follow-up with LLC coordination such as SNF, HH, HI, Rehab.
- Referrals to QM, DM, CM and AGD
- IPA oversight, Continuity of Care, Healthy Families activities, OOA/OON cases, invest/exp, POS
- Other CM activities as identified
- Support to senior/lead CMs as needed. Ability encompasses broad knowledge of concepts, practices and procedures required within health care field.
- Uses concepts and abilities as well as internal policies and procedures to complete assignments and solve problems.
- Generally requires moderate to thorough experience in nursing, health care or related field. (3-5 years)
- Generally requires a Bachelors degree or equivalent and appropriate licensing.