Top 197 Utilization management Jobs in San Jose, Ca

Utilization Management and Discharge Planning RN
Santa Clara Family Health Plan —San Jose, CA
- $100,968 - $151,451 a year
- Temporary
- Hybrid work
- Nursing
- Skilled nursing facility
- RN License
- Wellness program
- Health insurance
Quick Apply
Utilization Specialist - Full Time
San Jose Behavioral Health —San Jose, CA
- $33 - $50 an hour
- Full-time
- Acute care
- LMFT
- CPR Certification
2d
Medical Field Case Manager
Enlyte —San Jose, CA
- $100,000 - $108,000 a year
- Full-time
- Hybrid work
- Nursing
- Microsoft Outlook
- RN License
- Travel reimbursement
- Health savings account
Healthcare Operations Facility Administrator
Fresenius Medical Care —Fremont, CA
- $71,000 - $167,000 a year
- Full-time
- Microsoft Excel
- Heavy lifting
- Clinic
- Health insurance
- Dental insurance
Temp Medical Management Personal Care Coordinator
Santa Clara Family Health Plan —San Jose, CA
- $67,863 - $101,795 a year
- Temporary
- Spanish
- Clean driving record
- Microsoft Outlook
Temp Medical Management Care Coordinator I
Santa Clara Family Health Plan —San Jose, CA
- $55,958 - $81,139 a year
- Temporary
- Microsoft Outlook
- Word processing
- Writing skills
Community Based Program Coordinator
Santa Clara Family Health Plan —San Jose, CA
- $61,554 - $89,253 a year
- Full-time
- Spanish
- Clean driving record
- Writing skills
2d
Medical Management Personal Care Coordinator
Santa Clara Family Health Plan —San Jose, CA
- $67,863 - $101,795 a year
- Full-time
- Spanish
- Clean driving record
- Microsoft Outlook
Quick Apply
Manager, Healthcare Services - Remote (Must Reside in California)
Molina Healthcare —San Jose, CA
- $84,067 - $163,931 a year
- Full-time
- LMFT
- Nursing
- Microsoft Excel
- Health insurance
Utilization Management - RN
Bickham Services Unlimited, LLC —Sunnyvale, CA
- Contract
- Nursing
- RN License
- Bachelor of Science
Quick Apply
9d
Supervisor, Case Management
Santa Clara Family Health Plan —San Jose, CA
- $113,836 - $176,446 a year
- Full-time
- Spanish
- Clean driving record
- Microsoft Outlook
Quick Apply
Manager, Women's Comprehensive Health Center
Sutter Health —Santa Clara, CA
- $110,281.60 - $165,422.40 a year
- Weekends as needed
- Customer service
- Writing skills
- Employment & labor law
2d
Licensed Psychotherapist (DBT)
LGTC Group —San Jose, CA
- From $94,000 a year
- Full-time
- LMFT
- Licensed Clinical Social Worker
- Mid-level
- Dental insurance
- 401(k)
Quick Apply
Supervisor, Case Management (clinical)
Santa Clara Family Health Plan —San Jose, CA
- $113,836 - $176,446 a year
- Full-time
- Spanish
- Clean driving record
- Management
- Health insurance
- Dental insurance
Quick Apply
Bereavement Manager - LCSW
Pathways Home Health And Hospice —Sunnyvale, CA
- $89,045 - $122,625 a year
- Weekends as needed
- Google Workspace
- Microsoft Excel
- Licensed Clinical Social Worker
- Health insurance
- Paid time off
Quick Apply
Outpatient Medical Biller
Bay Area Surgical Management LLC —Santa Clara, CA
- $28 - $30 an hour
- Full-time
- Background check
- Microsoft Outlook
- Mid-level
- Health insurance
- Dental insurance
Quick Apply
Lead APP (NP/PA)- ENT Surgery- FT Days
Stanford Health Care —Palo Alto, CA
- $100.03 - $132.51 an hour
- Full-time
- Hybrid work
- Nursing
- Doctoral degree
- Surgery
SUPERVISOR FOR FAMILY MEDICINE
RAVENSWOOD FAMILY HEALTH CENTER —Palo Alto, CA
- $72,800 - $90,000 a year
- Full-time
- Spanish
- LVN
- Computer literacy
- On-the-job training
Quick Apply
Executive Director of MMC
Stanford Health Care- University Health Care Alliance —Menlo Park, CA
- $99.70 - $132.11 an hour
- Full-time
- Clinic
- Bachelor's degree
- Recruiting
- Health insurance
- Dental insurance
Quick Apply
12d
Manager, Radiation Therapy
Stanford Health Care —San Jose, CA
- $83.98 - $111.27 an hour
- Full-time
- Bachelor's degree
- Military encouraged
- Recruiting
- Continuing education credits
- Health savings account

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Utilization Management and Discharge Planning RN

Santa Clara Family Health Plan -
San Jose, CA

Quick Apply

Job Details

Temporary
$100,968 - $151,451 a year

Benefits

Wellness program
Health insurance
On-site gym
Dental insurance
401(k)
Flexible spending account
Tuition reimbursement
Paid time off
Employee assistance program
Vision insurance
401(k) matching
Life insurance
Referral program
Retirement plan

Qualifications

Medicare
Utilization review
Managed care
RN License
Pre-authorization review for utilization management
Case management
Utilization management
Centers for Medicare and Medicaid Services (CMS)
Healthcare compliance

Full Job Description

About Us:

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.

About the role:

The Utilization Management and Discharge Planning Nurse performs clinical review in accordance with applicable regulatory and professional standards for Organization Determination Requests using clinical experience and skills in a collaborative process to assess, plan, implement, coordinate and evaluate options to ensure appropriate utilization of member healthcare services and benefits for all lines-of-business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.

Day to Day:

Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective/claims review organization determination authorization requests within regulatory turnaround requirements for all SCFHP lines of business.
Complete authorization reviews by applying the appropriate clinical criteria/guidelines, policy, procedures and clinical judgment to render coverage determinations.
Document pre-admission status, including living arrangements, physical and mental function, social support, durable medical equipment (DME), and other services received.
Draft appropriate notification letters such as approval, denial, delay and modify notifications to providers and members and language threshold following regulatory requirements..
Perform onsite concurrent review activities, as needed in the home, facility or community setting. For Long Term Care UR RN: Conduct regularly scheduled on-site visits to contracted skilled nursing facilities to follow up on re-admissions, confirm member census, conduct member assessments and provide on-site utilization and concurrent review.
Review and monitor hospital or nursing facility census and internal reports to track, reconcile and update discrepancies in member case files. For Long Term UR RN: Monitor and oversee re-admission and transfer prevention strategy.
Facilitate and coordinate communication related to post discharge with member interdisciplinary care team (ICT) including physicians, specialists, public services, community agencies and vendors to ensure care plan development and coordination of benefits and services.
Apply the use of clinical judgment to identify and coordinate referrals to appropriate departments or programs for member identified continuity of care needs, such as Case Management, Behavioral Health, Managed Long Term Services and Supports (MLTSS), community resources, Pharmacy and Quality.
Proactively and collaboratively interface with external case management staff including delegates to facilitate discharge planning and care transitions.
Maintain adherence with Model of Care of CMC, LTSS and DHCS regulatory requirements.

About You:

Active California Board of Nursing License (RN) without restriction.
Minimum one year of licensed related health care experience.
Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management.
Knowledge of MediCal and/or Medicare guidelines and regulations.
One year of experience with a Managed Care Health Plan.
Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards.
Ability to make determinations based on Nursing knowledge when no criteria are available or applicable.
Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance.
Clinical knowledge and critical thinking skills with the ability to assess individualized whole-person care needs necessary to develop an effective care plan.
Experience working with designated member population (e.g. behavioral health, seniors and persons with disabilities, children).

Please review the full job description on our Career’s page: https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=3170

Job Type: Temporary

Pay: $100,968.00 - $151,451.00 per year

Benefits:

401(k)
401(k) matching
Dental insurance
Employee assistance program
Flexible spending account
Health insurance
Life insurance
On-site gym
Paid time off
Referral program
Retirement plan
Tuition reimbursement
Vision insurance
Wellness program

Application Question(s):

Do you have Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards?
Do you have experience in reviewing clinical criteria to make determinations?

Experience:

licensed related health care: 1 year (Required)
Managed Care Health Plan: 1 year (Preferred)
MediCal and/or Medicare : 1 year (Required)

License/Certification:

RN License (Required)

Work Location: Hybrid remote in San Jose, CA 95119

Quick Apply

Refine Your Search

utilization management jobs in san jose, ca

Utilization Management and Discharge Planning RN

Utilization Specialist - Full Time

Medical Field Case Manager

Healthcare Operations Facility Administrator

Temp Medical Management Personal Care Coordinator

Temp Medical Management Care Coordinator I

Community Based Program Coordinator

Medical Management Personal Care Coordinator

Manager, Healthcare Services - Remote (Must Reside in California)

Utilization Management - RN

Supervisor, Case Management

Manager, Women's Comprehensive Health Center

Licensed Psychotherapist (DBT)

Supervisor, Case Management (clinical)

Bereavement Manager - LCSW

Outpatient Medical Biller

Lead APP (NP/PA)- ENT Surgery- FT Days

SUPERVISOR FOR FAMILY MEDICINE

Executive Director of MMC

Manager, Radiation Therapy

I want to receive the latest job alert for utilization management in san jose, ca

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