Regional Case Management - Area Manager - RN
We are looking for an experienced RN for our Out of Area Manager, Regional Case Management position. Primary working 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 to pre-admission, ambulatory case management, inpatient, social service, home health, health education, behavioral health and other health care delivery programs within the health system.
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.
Manages staff directly responsible for the day-to-day operations of the care management programs. Contributes to the clinical, quality, financial and patient satisfaction outcomes of the region.
Identifies need for and participates in the development and implementation of care management and 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.
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.
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.
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, providers and others. These include an extensive orientation program, cross-training and proactive approach to case management.
Must be familiar with Medicare and managed care regulations.
Graduate from an accredited school of Nursing.
Current California RN license.
Bachelor’s degree in Nursing or related field preferred.
At least 3 years and up to 5 years of experience in case management.
3 to 5 years prior acute nursing experience.
Working knowledge of CMS, NCQA, DMCH, HEDIS, medical and regulatory agency guidelines.
Proficient in Microsoft applications (Word, Excel, Access).
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.