Facilitates cost effective care throughout the continuum utilizing a collaborative multi-disciplinary approach. Implements the nursing process including assessment, planning, implementing, coordinating, monitoring and evaluating options and services for patients and families experiencing complex/catastrophic illnesses. Responsible for the assurance of quality medical management and cost containment in the Utilization (Medical) Management department in the PMG/IPA. This includes, but is not limited to: utilization and referral management and total case management, in both the inpatient and outpatient settings.
Daily onsite rounds, reviewing of medical records, concurrent review, and discharge planning on inpatients with arrival at facilities in the morning ideally between 0800 and 0900
Daily inpatient rounds with Hospitalists
Communicates discharges to IPA by 12 noon
Reviews inpatient cases with UM Manager on a daily basis
Documents Milliman Guideline(s) on every inpatient case within 24 hours of receipt and updates guideline as hospitalization continues.
Notifies patient’s Primary Care Physician of admission, discharge and discharge plan within 24 hours of each event as appropriate.
Analyzes medical cases for appropriateness and plans and coordinates all phases of care in conjunction with the Hospitalist, attending Physician, Specialists both in the inpatient and outpatient settings.
Utilizes the nursing process to establish individual patient goals and measures patients’ response to the plan of care for appropriate outcomes and intervenes appropriately
Collaborates with physicians, patients, and families to formulate an optimal plan of care that meets all of the medical, psychosocial and financial needs of the patient
Explores care options to reduce cost, decrease length of stay, curtail re-admission and influence quality outcomes.
Understands capitation vs. fee for service.
Knowledgeable regarding network providers and current contracted specialists
Manages cases according to delegation agreement requirements, including notifications regarding LOS >5 days
Regularly communicates with Health Plans as appropriate
Understands health plan benefits and contractual information
Generates authorizations utilizing principles of UM
Accurately uses database for daily documentation of clinical information, opportunity days, denied days and levels of care.
Follows policy and procedure for Denials and enters this information into the database with 24 hours of the event.
Assists with implementation of all policies and procedures in the group through knowledge and experience.
Assists in training/crosstraining of staff, in conjunction with corporate department, to maximize effectiveness and utilize staff to their fullest potential.
Meets all health plan contract compliance directives for utilization.
Maintains ongoing communication and feedback with customers and/or clients in order to support needs and resolve problems.
Attends weekly/monthly group committees as requested.
Manages error reports on a weekly basis
Communicates activities and progress of assigned committees and teams to appropriate staff.
Identifies and refers members to Case Management prior to discharge or as deemed appropriate through referral review
Participates in IPA Grand Rounds providing a concise history and overview of the member’s progress and discharge plan. Attends any onsite specialty facility rounds as appropriate.
Performs On Call duties after hours and on weekends as requested and contacts facilities regarding patients expected to discharge or be transferred. Assures discharge plans are implemented. Confers with Hospitalist on call as appropriate.
Other duties as assigned.
AA, Bachelor's Degree
RN or LVN with current California license
1 - 4 years clinical experience in acute care (ie ICU, CCU, ER, med-surg) or related healt care experience
3 years managed care experience
NAMM North America Medical Management - 16 months ago