The posting
Job Description
At NorthBay Healthcare the Utilization Management (UM) is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost effective outcomes.
UM Case Managers work under the direction of the Manager of UM and the AVP of Care Coordination. UM Case Managers work across the continuum of the system in collaboration with patients, physicians, staff, broker services and administration to ensure appropriate care at the appropriate level to the high-risk members.
The UM Case Manager utilizes clinical knowledge and competence, positive communication skills, problem solving and conflict resolution techniques, ability to effect change, strong skills in assessment, organization, and time management. The UM process requires a focus on critical thinking skills, customer service skills, setting appropriate goals and measuring outcomes to effectively ensure optimal patient outcomes with consideration to financial and healthplan resources. The UM Case Manager at NorthBay Healthcare must be able to demonstrate adherence to the department and system policies, procedures, quality assurance, guidelines and goals of the department and the organization.
PRIMARY JOB DUTIES
- Works across the continuum of ambulatory, hospital and ancillary services to coordinate care for the patient at the appropriate level.
- Serves as liaison with the Health Plans.
- Authorizes and monitors internal, external and out-of-area admissions and services.
- Identifies high-risk patients utilizing health risk assessment tools, referral forms and Midas reports.
- Coordinates care of patient with the physician, clinical/hospital staff and family members to ensure utilization of the appropriate level of care.
- Serves as resource for physicians and staff on matters concerning Health Plan benefits, restrictions and limitations.
- Assesses the needs of capitated members for durable medical equipment, home health, and skilled nursing placement and authorizes appropriately.
- Works with the capitated Health Plan to repatriate member back into the NorthBay Healthcare System when appropriate.
- Applies NorthBay Healthcare System approved UM decision criteria to the management of complex and chronic cases.
- Assesses, plans, implements, coordinates and evaluates individualized treatment plans for the case managed patient.
- Applies benefits appropriately. Authorizes exceptions to benefits on a case by case basis when in the best interest of the patient and the System.
- Coordinates care with Medical Group UM department.
- Notifies appropriate personnel of out-of-area admission in a timely manner.
- Complies with NorthBay Hospital approved time frames and standards for timeliness of UM decision-making.
- Identifies and refers members to Health Plan who meet the Health Plan’s criteria for evaluation for special financial status.
- Other duties as assigned.
Qualifications
Education:
- Graduate of an accredited school of nursing.
- BSN required.
Licensure:
- Current California RN License.
- Certified Case Manager or American Case Management accreditation preferred.
Skills:
- Strong acute hospital background.
- Knowledge of Health Plan rules and regulations
Experience:
- Minimum of 1-year Utilization Management experience with processing authorizations/denials preferred
