Utilization Management And Discharge Planning RN

FLSA Status: Non-Exempt

Department: Health Services

Reports To: Health Services Management

Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521

GENERAL DESCRIPTION OF POSITION

The Utilization Management and Discharge Planning Nurse performs clinical review in accordance with applicable regulatory and professional standards for Organization Determination Requests using clinical experience and skills in a collaborative process to assess, plan, implement, coordinate and evaluate options to ensure appropriate utilization of member healthcare services and benefits for all lines-of-business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

• Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective/claims review organization determination authorization requests within regulatory turnaround requirements for all SCFHP lines of business.
• Complete authorization reviews by applying the appropriate clinical criteria/guidelines, policy, procedures and clinical judgment to render coverage determinations.
• Document pre-admission status, including living arrangements, physical and mental function, social support, durable medical equipment (DME), and other services received.
• Draft appropriate notification letters such as approval, denial, delay and modify notifications to providers and members and language threshold following regulatory requirements.
• Perform onsite concurrent review activities, as needed in the home, facility or community setting.
• Review and monitor hospital or nursing facility census and internal reports to track, reconcile and update discrepancies in member case files.
• Facilitate and coordinate communication related to post discharge with member interdisciplinary care team (ICT) including physicians, specialists, public services, community agencies and vendors to ensure care plan development and coordination of benefits and services.
• Apply the use of clinical judgment to identify and coordinate referrals to appropriate departments or programs for member identified continuity of care needs, such as Case Management, Behavioral Health, Managed Long Term Services and Supports (MLTSS), community resources, Pharmacy and Quality.
• Proactively and collaboratively interface with external case management staff including delegates to facilitate discharge planning and care transitions.
• Maintain adherence with Model of Care of CMC, LTSS and DHCS regulatory requirements.
• Facilitate appropriate processing of Letters of Agreement with non-contracted Providers for approved medically necessary services.
• Participate in new and ongoing clinical Quality Improvement initiatives.
• Perform other duties as required or assigned.

REQUIREMENTS - Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

• Active California Board of Nursing License (RN) without restriction. (R)
• Minimum one year of licensed related health care experience. (R)
• Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management. (R)
• Knowledge of MediCal and/or Medicare guidelines and regulations. (D)
• One year of experience with a Managed Care Health Plan. (D)
• Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards. (D)
• Ability to make determinations based on Nursing knowledge when no criteria are available or applicable. (R)
• Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)
• Clinical knowledge and critical thinking skills with the ability to assess individualized whole-person care needs necessary to develop an effective care plan. (R)
• Experience working with designated member population (e.g. behavioral health, seniors and persons with disabilities, children). (D)
• Ability to work within an interdisciplinary team structure. (R)
• Ability to conduct home, facility and other community-based visits. (R)
• Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R)
• Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the operations as dictated by business needs. (R)
• Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific case management programs. (R )
• Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
• Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing as mandated by nursing scope of practice. (R)
• Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
• Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
• Ability to maintain confidentiality. (R)
• Ability to comply with all SCFHP policies and procedures. (R)
• Ability to perform the job safely and with respect to others, to property and to individual safety. (R)

WORKING CONDITIONS

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

• Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
• Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
• Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
• Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
• Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
• Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.