Provides assistance with oversight during the daily operations of the outpatient review process. Participates in the training and mentoring of team members. Provides support, resources, and direction to staff. Assists in determining appropriateness, quality, and medical necessity of requested service.
Education and Experience
RN or LVN, with two (2) years of managed care (case management) experience; or equivalent combination of education and experience. General knowledge of managed care with emphasis in utilization and/or case management preferred.
Special Skills, Licenses and Certifications
Licensed or certified in nursing, case management, or Certified Professional in Healthcare Quality (CPHQ). Strong knowledge of nursing requirements in a clinical setting. Knowledge of utilization management programs as related to use of pre-set criteria and protocols. Familiarity with business practices and protocols with ability to access data and information using automated 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. Ability to understand and follow 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 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. Cubicle work station. Ability to use a computer keyboard. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs.
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.