Initiates and coordinates a multidisciplinary team approach to case management and handling of grievances with members, providers, CMO, departmental directors, managers, and others to evaluate, monitor, and assure that medically necessary services are provided in a quality, efficient, and timely manner. This position may be assigned cases requiring case management, disease management, or special initiative programs.
SECONDARY DUTIES AND RESPONSIBILITIES
Education and Experience
Bachelor’s degree in Nursing, 3-5 years experience to include at least one (1) year of case management experience and one (1) year in an acute care setting; or equivalent combination of education and experience. CCM desired. Knowledge of PHC Grievance and Appeals processes. General knowledge of managed care with emphasis in UM or CM preferred.
Special Skills, Licenses and Certifications
Current California Registered Nurse license. Thorough knowledge of utilization and case management programs and related criteria and protocols. Experience in managed care business practices and ability to access data information using computer systems. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines. Strong organizational skills required. Effective telephone and computer data entry skills required. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
Performance Based Competencies
Excellent written and verbal communication skills with ability to read and interpret benefit contract specifications are required. Ability to understand and ensure compliance with established criteria and protocols used in managed care functions. Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses. Ability to apply clinical judgment to complex medical situations and make quick decisions. Ability to communicate effectively with coworkers, members, their families, physicians, and health care providers.
Work Environment And Physical Demands
Daily use of telephone and computer for most of the day. Standard cubicle workstation. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs.
Additional Preferred Skills: Current RN license. Experience in managed care business practices and ability to access data information using computers systems. General knowledge of managed care with emphasis in UM or CM preferred. Effective telephone and computer data entry skills.
All HealthPlan employees are expected to:
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.