UM Nurse responsible for medical necessity reviews and care coordination for a population of members, ensuring quality and cost-effective outcomes.
Responsibilities
Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
Review cases for medical necessity and apply appropriate clinical criteria including Medicare, Medicaid/Medi-cal, InterQual, Milliman, and Health Plan specific guidelines
Collaborate with the Medical Director to ensure integrity of adverse determination notices
Ensure discharge planning is timely and communicated to transition of care teams
The RN Case Manager provides case management for assigned patient populations, utilizing clinical expertise, communication and problem-solving skills to achieve optimal clinical and resource outcomes.
Compensation
Sign on bonus and relocation assistance available
Responsibilities
Provide case management for assigned patient populations
Performs patient needs assessments upon admission and at regular intervals
Facilitates referrals and providing linkages to health, wellness, and post-acute care resources
Promotes interdisciplinary collaboration and teamwork to progress the plan of care and discharge plan
Promotes appropriate length of stay, resource management, and care transitions
Requirements
Registered Nurse
Nice to have: Bachelor's degree
Nice to have: Supervisory or leadership experience
RN Case Manager provides case management for patient populations, utilizing clinical expertise and problem-solving skills to achieve optimal outcomes and facilitate care transitions.
Compensation
$76,689.60 - $115,044.80
Responsibilities
Performs patient needs assessments upon admission and at regular intervals
Facilitating referrals and providing linkages to health, wellness, and post-acute care resources
Promotes interdisciplinary collaboration and teamwork to progress the plan of care and discharge plan
Promotes appropriate length of stay, resource management, and care transitions
Comply with all federal and state regulations surrounding the discharge process
Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas
Applies established criteria and employs clinical expertise to interpret clinical criteria to determine medical necessity of services
Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members
Provides decision-making guidance to clinical teams on service planning as needed
Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures
The Care Management Coordinator is responsible for overseeing the processes and documentation that occur as evidence based practice is applied at the bedside, directing and completing all functions of the government and commercial utilization management process, and coordinating the discharge plan.
Responsibilities
Assesses and coordinates implementation of the discharge plan
Collaborates with multidisciplinary team to assure effective, efficient, appropriate care
Performs utilization review for patients served
Directs and or completes all functions of the government and commercial utilization management process
Ensures CMS requirements are met for patient status
Requirements
Associate's Degree
Diploma in Nursing
BSN within 5 years of hire
Nice to have: Professional organization membership
Provides case management for assigned patient populations, utilizing clinical expertise, communication, and problem‑solving skills to achieve optimal clinical and resource outcomes.
Compensation
$76,689.60 - $115,044.80
Responsibilities
Performs patient needs assessments upon admission and at regular intervals
Facilitates safe and effective transitions of care
Provides concurrent review and prior authorizations for Molina Healthcare members, ensuring appropriate utilization of inpatient and outpatient services.
Responsibilities
Conducts daily review and evaluation of members requiring hospitalization or procedures
Provides prior authorizations and concurrent reviews per Molina policy
Identifies appropriate benefits, eligibility, and expected length of stay
Participates in interdepartmental integration and collaboration
Maintains department productivity and quality measures
Requirements
Completion of an accredited Registered Nursing program
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