SUMMARY: Performs onsite or telephonic clinical review for the acutely hospitalized Monarch HealthCare member or member in the Skilled Nursing Facility environment. Actively implements a plan of care utilizing approved clinical guidelines to transition and provide continuity of care for the member to an appropriate lower level of care in collaboration with the hopitalist/physician team, acute or skilled facility staff, ambulatory care team, and the member and/or member's representative from admission through discharge.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
1. Performs concurrent and retrospective onsite or telephonic clinical review at the designated network or out-of-network facilities as needed/directed by the ICPS Management team (Director, Manager, and Supervisors) documenting medical necessity and appropriate level of care utilizing clinical guidelines (e.g. Milliman, Interqual). Complies with CMS regulations and Health Plan requirements.
2. Interacts and effectively communicates with members, their families and/or designated member representative to assess discharge needs and formulate discharge plan, provide Health Plan benefit information, and services available based on clinical need.
3. Interacts daily with treating physicians regarding the Monarch HealthCare member's plan of care and alternative care solutions. Consults the Monarch Medical Director/designee for unusual and complex cases.
4. Effectively communicates plan of care to facility staff, health plan partners, and Ambulatory Case Management (ACM) to ensure understanding treatment plan and clinical needs at time of transition to lower level of care.
5. Efficiently navigates and utilizes computer data entry programs including, but not limited to: Microsoft Office (Outlook, Word, and Excel), RightFax, Adobe Reader for fax attachment process.
6. Provides guidance and benefits information for members and their families and facility discharge planners.
7. Documents and maintains a Continuity Plan of Care for the Monarch HealthCare member by assessing and identifying continued needs upon discharge to encompass; health services, durable medical equipment, hospice, follow-up physician appointments, skilled versus sub-acute versus custodial levels of care.
8. Issues the appropriate denial letters based on Health Plan or CMS guidelines utilizing ICE language.
9. Identifies and reports all institutionalized, ESRD and hospice patients, and appropriately refers members with special transition needs or disease management to ACM.
10. Performs on call duties as scheduled on a rotating basis.
11. Identifies Quality Improvement (QI) indicators and provides timely reporting to the QI department.
12. Actively participates in the orientation and ongoing training of new employees as needed.
13. Actively participates in the ongoing development of IPCS by participating in task forces for policy and procedure review/revision/development, staff meetings, and other departmental meetings/committees promoting Monarch HealthCare's core ideals and values.
14. Regular and consistent attendance.
EDUCATION and/or EXPERIENCE: Graduate of an accredited School of Nursing. BSN or equivalent desirable. Minimum of 3 years recent acute care or managed care experience. Current and valid, unrestricted California state nursing license. CCM preferred.
LICENSES, CERTIFICATES, REGISTRATIONS: Current State of California Registered Nursing License. CCM or CPUR preferred. Current/valid California Driver's License with current insurance.
LANGUAGE SKILLS: Ability to read and analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquires or complaints from customers, regulatory agencies, or members of the business community. Ability to write speeches and articles from publications that conform to prescribed style and format. Ability to effectively present information to top management, public groups, and/or boards of directors.
MATHEMATICAL SKILLS: Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
OTHER SKILLS and ABILITIES:
Prior geriatric or physical rehabilitation experience (preferred for SNF CM role). Computer knowledge and ability to navigate various databases.
Must be proficient with Microsoft Office with working knowledge of Excel and excellent knowledge of Word.
Requires driving from office to facilities. Must possess and maintain a current/valid California Driver's License.
PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to use hands to finger, reach with hands and arms, talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl.
While performing the duties of this job, the employee is frequently required to lift and or exert force up to 10 pounds and occasionally required to lift and or exert force up to 25 pounds.
WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually moderate.
Monarch HealthCare is proud to be part of OptumHealth!
OptumHealth is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
OptumHealth helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their health care needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.
At OptumHealth, you will perform within an innovative culture that's focused on transformational change in the health care system. You will leverage your skills across a diverse and multi-faceted business. And you will make contributions that will have an impact that's greater than you've ever imagined.
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.
Skills / Requirements
Monarch HealthCare - 14 months ago