OVERVIEW OF POSITION:
Seeking an experience LVN with case management and utilization management experience to oversee our utilization management team in Torrance, CA.
Primary hours are Monday- Friday 8AM-5PM
Responsible for the oversight, management and optimization of all quality improvement, utilization management and care management activities as it relates health care delivery programs within Health Care Partners Medical Group. Manages staff directly responsible for the day-to-day operations of the utilization management programs. Contributes to the quality, financial, and patient satisfaction outcomes of the region. Works closely with all members of the Care Management team as well as members of Health Enhancement, Quality Improvement, Contracting and the Office of the Medical Director to ensure compliance with all regulatory requirements.
Identifies need for and participates in the development and implementation of utilization management policies and procedures, and ensures compliance throughout the region.
Monitors the utilization of inpatient and outpatient services and ensures coordination of all ambulatory care management services with pre-admission, home health, health education and other ambulatory services.
Closely monitors and analyzes all inpatient and outpatient reports and identifies trends. Makes recommendations to the Director regarding interventions to improve all resource management.
Facilitates team process problem resolution using HCP administration, Medical Directors, Contracting, Risk Management, Behavioral Health and health plans regarding complex patient issues. Implements the results of the collaboration process.
Oversees and monitors patient eligibility, financial contract accountability and health plan benefit determination for each patient referral. Facilitates resolution on areas of conflict.
Prepares the department for accreditation surveys using the appropriate standards of performance. Ensures utilization management compliance with DMHC/CMS/NCQA requirements.
In conjuction with the local Care Management Committee, leads activities related to the utilization review process.
Designs, implements and facilitates data and statistical collection including outcome and quality of care information.
Monitors all high risk/high cost patients in regard to care delivery, referrals, contracting, etc. Monitors provider referral patterns for appropriate utilization of specialty and ancillary services.
Provides supervision and guidance to staff.
Conducts monthly staff meetings including utilization management review outcome measurements and identification of training/educational opportunities.
Identifies, develops and oversees the educational needs of care management staff, and providers.. These include an extensive orientation program, cross-training and proactive approach to case management.
Identifies opportunities for the development of new care management approaches and prepares proposals with cost analyses, IS requirements, education and implementation plans.
Contributes to the Care Management business plan and budget process along.
Coordinates or performs projects/activities as delegated by organizational committees.
Uses, protects, and discloses HCP patients’ protected health information only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
1 or 2 years of post-high school education or a degree from a two-year college.
Graduate from an accredited 1 or 2-year LVN program.
Current California LVN license.
Over 3 years and up to and including 5 years of experience.
3 to 5 years prior acute nursing experience.
3 to 5 years prior acute nursing with critical care experience.
2 to 4 years managed care/HMO experience in utilization review, case management or discharge planning.
2 to 3 years management experience in utilization review, case management or discharge planning.
KNOWLEDGE, SKILLS, ABILITIES:
Proficient in Microsoft applications (Word, Excel, Access).
Knowledge of medical/nursing standards of care.
Working knowledge of CMS, NCQA, DMCH, HEDIS, medical and regulatory agency guidelines.
Ability to effectively collaborate with physicians, patients/families and ancillary staff.
Strong oral/written analytical and problem-solving skills with ability to make sound and independent judgments.
Ability to act professionally under pressure