Physician / Pediatrics / California / Locum or Permanent / RN, Utilization Management, Pediatrics - Irvine, CA JobOptumCare • Irvine, California, United States
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Physician / Pediatrics / California / Locum or Permanent / RN, Utilization Management, Pediatrics - Irvine, CA Job
OptumCare
- Irvine, California, United States
- Irvine, California, United States
Über
The Utilization Management RN is responsible for the facilitation of the inpatient Utilization Management process including in - network, out of network, case management and discharge planning as well as assisting the Associate Director of Inpatient Management with UM / QM functions as necessary. Acts as a facility liaison to promote cooperation and efficiency between the IPA and the facility. This is an office based position, located in Irvine, CA that requires some travel (up to 30%) in the Orange County area. There is a one time sign on bonus of $5,000 for this position!
Primary Responsibilities:
- Directly performs concurrent review
- Accurately identifies and documents level of care
- Coordinates, facilitates and documents comprehensive discharge planning
- Coordinates in - network services for out of network discharges
- Ensures the appropriate utilization of in network, capitated and contracted specialists, providers, facilities, and vendors according to region and risk
- Attends daily inpatient readmission review rounds and presents cases to medical director(s), Case managers and post acute services
- Facilitates out of network transfers to In - Network facilities
- Works collaboratively with internal and hospital contract staff :
- Initiates letter of agreement for OON services in a timely manner
- Provides input for potential contracts
- Identifies and communicates high dollar / high risk cases
- Oversees the utilization of contracted facilities and reports OON utilization
- Develops and maintains relationships with both network and Out of Network hospital UM and ER staff
- Works directly with Monarch Hospitalists to develop and implements inpatient processes including, but not limited to:
- Identification of patients and referral to specialty clinics such as Comprehensive Care (high - risk) Clinic, Anti - coagulation and / or Diabetic Clinic
- Facilitates and ensures timely communication between PCP and Hospitalists
- Provides direct Case Management activities if necessary
- Identifies readmit for CM coordinations
- Identifies Healthy Families and Medi - Cal members for CCS referral and facilitates those referrals
- Identifies and coordinates high dollar / high risk patients to case management
- Participates in UMC / QIC, PCP, Provider Office Meetings, health plan JOMs, and hospital JOCs as assigned
- Participates in inpatient UM / QM projects and completes in a thorough and timely manner
Sprachkenntnisse
- English
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