Utilization Management/ Nurse Case Manager

About Us

PremierOne Plus MSO (POPMSO) is a management service organization serving the needs of providers in a managed care setting. PremierOne Plus MSO provides you with the resources and opportunity to build a rewarding career in an environment that support your success. This is an in-person job. There are no remote options.

Description

• Responsible for utilization management, utilization review, or concurrent review (telephonic inpatient care management).
• Perform reviews of current inpatient services and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines (Milliman) and benefit determination.
• Perform medical necessity and level of care reviews for requested medical services and refer to Medical Directors for review as appropriate depending on case development

Responsibilities and Duties

• Performing care management activities to ensure that patients move through the continuum of care efficiently and safely.
• Assesses and interprets customer needs and requirements.
• Reviewing cases and analyzing clinical information in conjunction with Medical Directors to determine the appropriateness of hospitalization.
• Performing Nurse to Physician interaction to acquire additional clinical information or discuss alternatives to current treatment plan.
• Escalating cases to the Medical Director for case discussion or peer-to-peer intervention as appropriate.
• Performing anticipatory discharge planning in accordance with the patient's benefits and available alternative resources.
• Referring patients to disease management or case management programs.
• Assisting with the development of treatment plans.
• Documenting activities according to established standards.
• Identifies solutions to non-standard requests and problems.
• Solves moderately complex problems and / or conducts moderately complex analyses.
• Works with minimal guidance; seeks guidance on only the most complex tasks.
• Provides explanations and information to others on difficult issues.
• Acts as a resource for others with less experience.
• Works with less structured, more complex issues.
• Update and review the case management and utilization management policies and procedures as needed
• Oversee the outpatient UM department
• Work on health plan initiated audits related to case management, utilization management, and related audits
• Submit and implement corrective action plans for issues identified during health plan audits

Qualifications and Skills

Basic Qualifications:

• Current and unrestricted RN or LVN License in the State of California.
• Clinical experience in an inpatient / acute setting.
• Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.
• Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
• Intermediate computer skills - Proficiency with Microsoft Word, Outlook and Internet Explorer, with the ability to navigate a Windows environment.

Preferred Qualifications:

• 1 year Utilization Management Inpatient experience.
• Utilization Review experience.
• Knowledge of or experience with Milliman Care Guidelines.
• Experience in discharge planning or chart review.
• Experience in acute long term care, acute rehabilitation, or skilled nursing facilities.
• A background that involves utilization review for an insurance company or in a managed care environment.

Work Remotely

• No

Schedule

• Weekdays, Monday to Friday
• 8:30 AM to 5:30 PM, whole duration
• Full-time

Salary

• Starting from $33 per hour
• Negotiable
• Depends on exact and relevant experience.

Job Type: Full-time

Pay: From $33.00 per hour

Benefits:

• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Application Question(s):

• Do you have case management experience? If so, how much?

License/Certification:

• LVN license (Preferred)
• RN License (Preferred)

Ability to Commute:

• Buena Park, CA Required)

Work Location: In person