Utilization Management/ Nurse Case Manager (NOT REMOTE) PremierOne Plus

MSO - 4.3

Buena Park, CA Job Details Full-time From $33 an hour 15 hours ago Benefits Health insurance Dental insurance Paid time off Vision insurance Qualifications Microsoft Outlook Word embeddings Windows Acute care facility experience Desktop applications Full Job Description About Us PremierOne Plus MSO (POPMSO) is a management service organization serving the needs of providers in a managed care setting. PremierOne Plus MSO provides you with the resources and opportunity to build a rewarding career in an environment that support your success. Responsible for utilization management, utilization review, or concurrent review (telephonic inpatient care management). Perform reviews of current inpatient services and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines (Milliman) and benefit determination. Perform medical necessity and level of care reviews for requested medical services and refer to Medical Directors for review as appropriate depending on case development Responsibilities and Duties Performing care management activities to ensure that patients move through the continuum of care efficiently and safely. Assesses and interprets customer needs and requirements. Reviewing cases and analyzing clinical information in conjunction with Medical Directors to determine the appropriateness of hospitalization. Performing Nurse to Physician interaction to acquire additional clinical information or discuss alternatives to current treatment plan. Escalating cases to the Medical Director for case discussion or peer-to-peer intervention as appropriate. Performing anticipatory discharge planning in accordance with the patient's benefits and available alternative resources. Referring patients to disease management or case management programs. Assisting with the development of treatment plans. Documenting activities according to established standards. Identifies solutions to non-standard requests and problems. Solves moderately complex problems and / or conducts moderately complex analyses. Works with minimal guidance; seeks guidance on only the most complex tasks. Provides explanations and information to others on difficult issues. Acts as a resource for others with less experience. Works with less structured, more complex issues. Update and review the case management and utilization management policies and procedures as needed Work on health plan initiated audits related to case management, utilization management, and related audits

Qualifications and Skills Basic Qualifications:

Current and unrestricted RN or LVN License in the State of California. Clinical experience in an inpatient / acute setting. Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action. Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. Intermediate computer skills - Proficiency with Microsoft Word, Outlook and Internet Explorer, with the ability to navigate a Windows environment.

Preferred Qualifications:

1 year Utilization Management Inpatient/Outpatient experience. Utilization Review experience. Knowledge of or experience with Milliman Care Guidelines. Experience in discharge planning or chart review. Experience in acute long term care, acute rehabilitation, or skilled nursing facilities. A background that involves utilization review for an insurance company or in a managed care environment. Work Remotely No Schedule Weekdays, Monday to Friday 8:30 AM to 5:30 PM, whole duration

Job Type:

Full-time Salary Starting from $33 per hour Negotiable Depends on exact and relevant experience.

Job Type:

Full-time Pay:

From $33.00 per hour

Benefits:

Dental insurance Health insurance Paid time off Vision insurance Application Question(s): Do you have case management experience? If so, how much?

License/Certification:

RN License (Preferred) LVN License (Preferred)

Work Location:

In person