Executive / Officer - Industrial Engineering (Word Study)
Jafferjee Brothers Exports (Pvt) Ltd
Salary $75,936 - $106,000 a year medical specialty home health job type full-time number of hires for this role 1
Full job description
Lvn or rn , the case management nurse performs complicated case reviews and first level determination approvals for inpatient, outpatient, and ancillary services requests, exclusive to a state health plans population (e.gMedi-cal)Reviews include benefit determination, medical appropriateness, and medical necessity determination requiring considerable clinical judgment, independent analysis, critical-thinking skills, and detailed knowledge of departmental procedures and clinical guidelinesCm nurse acts as liaison between the member/patient, the primary care provider, specialist(s), ancillary provider, and the designated health plan (e.gGold coast health plan, inc.) to promote appropriate and cost effective use of medical resources.
The position may require telephonic, web based, and onsite clinical reviews; therefore, the employee may need to use their private auto for travel to our various health centers, contracted hospitals, or other locations for offsite meetings.
Essential duties and responsibilities
Cm nurse’s responsibilities include, but are not limited to:
· conduct clinical review for inpatient, out-patient and ancillary services requests for medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans.
· review, triage, and prioritize authorization requests to meet required turn-around times.
· expedite access to appropriate care for members with urgent or immediate needs using the expedited review process.
· perform research and analyze complex issues, assesses member needs.
Graduate of an accredited nursing program required (e.gAsn, adn, bsn, msn).
V bachelor's degree preferred.
Active, valid, & unrestricted state of california registered nurse license is required.
Um/cm certification preferred.
Clean california driver’s license and automobile insurance is required.
Minimum three years clinical experience is required.
Minimum two years managed care experience, including discharge planning, case management, utilization management, home health, transplant, or related experience required.
Health plan experience preferred.
Knowledge, skills & abilities:
Strong knowledge of ncqa, federal and state regulations/requirements and/or jcaho criteria.
Demonstrated ability for assessment, evaluation and interpretation of medical information.
Possess a high level of understanding of community resources, treatment options, home health, funding options, and special programs.
Strong analytical and problem solving skills preferred.
Excellent verbal and written communications skills.
Excellent case preparation and abstracting skills.
A team player who builds effective working relationships.
Ability to work independently.
Experience using standardized clinical guidelines/criteria (e.gMilliman, interqual medi-cal criteria) required.
Strong organizational skills.
Able to operate pc-based software programs including proficiency in ms word.
Ability to effectively analyze, interpret, apply and communicate policies, procedures and regulations.
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.
Job type: full-time
Pay: $75,936.00 - $106,000.00 per year
Continuing education credits
Employee assistance program
Health savings account
Paid time off
Monday to friday
All employees are required to wear masks and we practice social distancing
This job is:
A job for which military experienced candidates are encouraged to apply
A job for which all ages, including older job seekers, are encouraged to apply
Waiting period may apply
Only full-time employees eligible