Full time RN, Utilization Manager for our Care Management Department, Roma location
Overview of Position: Responsible for timely, accurate medical review, determining if requests for services to be provided to DaVita Medical Group patients meet criteria for coverage based upon medical policies, guidelines, and health plan criteria. Responsible for review of inpatient length of stay for compliance with medical policies, guidelines, and health plan criteria. Based on criteria may refer cases to Medical Director Care Management for further review. Ensures compliance to contractual and service standards as identified by relevant health insurance plans and DaVita Medical Group. This is performed under the direct supervision of the Medical Director, Care Management.
* Provides timely, accurate review of precertification and prior authorization requests, for compliance with applicable medical policies and health plan benefits.
* Provides concurrent medical review of inpatient length of stays to ensure compliance with applicable medical policies and health plan benefits.
* Responsible for providing both outpatient and inpatient medical management review as needed, to ensure that patient healthcare requirements and organizational goals are met in a reasonable and medically appropriate manner.
* Ensure communication regarding medical reviews are provided to relevant patients and Providers in a timely manner, and in compliance with contractual agreements.
* Ensures compliance with HIPAA and other applicable company policies and procedures as well as regulatory requirements.
* Identify and address opportunities for quality improvement in all aspects of serving our customers. Assist in planning and implementation of systems changes and procedures to achieve overall organizational objectives.
* Maintain effective communication with management regarding development within areas of assigned responsibilities and performs special projects as required.
* Performs other duties as assigned.
* Required: Associates degree in Nursing
* Preferred: Bachelors degree in Nursing; Certified Case Manager
* Required: Three (3) years of previous job related experience in a healthcare environment.
* Preferred: Two (2) years experience providing case management and/or utilization review functions within health plan or integrated system.
Knowledge, Skills, Abilities:
* PC proficient; ability to communicate and interact professionally with co:workers, management patients, and Providers; ability to counsel and/or consult; working knowledge of HMOs, PPOs, Medicare, Medicaid, and insurance plans; knowledge of CPT4/ICD 9 and 10/HCPCS codes.
Licensure: Required: Valid, unrestricted, NM RN License or valid multi:state compact license. Must be 21 years or older and have a valid NM State Drivers license. Preferred: Utilization Review or Case Management Certificate.
Additional Requirements: Must pass a nationwide criminal history screen through the Caregivers Criminal History Screening Program
Whats the first thing that happens when one of the leading independent medical groups in the country comes together with a global leader in health care? Opportunity. With DaVita Medical Group, HealthCare Partners, The Everett Clinic, Northwest Physicians Network, MountainView Medical Group and Magan Medical Clinic joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. Were changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do your lifes best work.(SM)
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