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
Essential Duties and Responsibilities
▪ Oversees daily operation of the outpatient review process.
▪ Provides direction and support, to staff concerning daily assignments.
▪ Provides training in outpatient review to new hires.
▪ Provides performance feedback to the UM Team Manager.
▪ Participates in the interview process of new hires.
▪ Evaluates appropriateness of care through interpretation of benefits as outlined in Title
22, Medi-Cal Provider Manual, DMHC CMS regulatory requirements, using PHC
policies and procedures, and InterQual criteria for each product line.
▪ Documents and maintains patient-specific records in the appropriate data collection
software system.
▪ Assists in the refinement/improvement of the Health Services programs. Participates in
continuous process improvement endeavors.
▪ Works with other PHC departments to resolve issues relating to authorization of
medical services.
▪ Participates in Inter-rater Reliability studies, reviewing medical records as assigned.
▪ This position, in addition to their own case load, may require other review
responsibilities as deemed necessary to provide coverage.
▪ Communicates regularly with the UM Team Manager and works collaboratively to
resolve issues.
▪ Seeks UM Team Manager assistance as needed while coordinating work, making
decisions, and handling questions or problems.
▪ Participates in special projects and assignments as required.
Education and ExperiencE | Licensed Vocational Nurse (LVN) or Registered Nurse (RN),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.
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Special Skills, Licenses and Certifications | Current California Licensed Vocational Nurse (LVN) or Registered Nurse (RN),
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Performance Based Competencies | Excellent written and verbal communication skills with ability to read
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Work Environment And Physical Demands | Ability to prioritize workload and function effectively with frequent
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All HealthPlan employees are expected to:
HIRING RANGE:
LVN: $49.54 - $64.41
RN: $56.98 - $74.07
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 or definitive 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.
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