Hours:
Shift Start Time:
8 AM
Shift End Time:
4:30 PM
AWS Hours Requirement:
8/40 - 8 Hour Shift
Additional Shift Information:
Weekend Requirements:
As Needed
On-Call Required:
Yes
Hourly Pay Range (Minimum - Midpoint - Maximum):
$57.740 - $74.490 - $83.440
The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.
What You Will DoThis position is responsible for performing effective acute and ambulatory case management, utilization management and claims review activities, to ensure appropriate, cost-effective care to Sharp Health Plan (Plan) members, while always maintaining the highest quality of service.
Required Qualifications- Other Graduate of an NLN-accredited School of Nursing
- 2 Years Behavioral Health and Medical Nursing experience.
- California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED
Preferred Qualifications- Bachelor's Degree in Nursing
- 3 Years Utilization, quality, and/or case management experience in managed care setting.
Essential Functions
- Authorizations
Authorization of medically necessary patient care services and appropriate levels and types of services. Utilize Sharp Health Plan Medical Policies in conjunction with Milliman Care Guidelines for medical necessity approvals and referrals to the Plan Medical Director. Ensure all denial letters include the appropriate and individualized denial reason and alternate plan of care as determined by the Plan Medical Director.
- Care coordination and advocacy
Utilization of the Nursing Process in the coordination of the delivery of health care services to a specified population of members: Assessment, Planning, Implementation and Evaluation.
Coordination of care between the primary physician, specialists, vendors, community services and client/caregiver including extra-contractual case by case rate negotiations.
In conjunction with the patient and family physician, develop a care plan for the delivery of acute or community based services. The case manager will coordinate all care, negotiate service arrangements as directed by the Health Services Manager, and ensure that all caregivers and vendors are involved with the care plan.
Maintain detailed, accurate and timely data files on each client adhering to program guidelines.
Participate with the approval of Manager of Health Services in the planning / implementation of health education/quality improvement initiatives that have a case management component.
- Claims management
Provide Prospective, Concurrent, Retrospective and Claims Review and Care Management services for Sharp Health Plan members who are identified as having complex health or functional requirements or are candidates for a disease management program to maximize responsiveness to care plan and attainment of goals.
Effective communication and screening of client, in-home assessment, care planning, arranging and coordinating services, monitoring, and consistently reassessing needs and services for members on a pre-service, concurrent and/or retrospective basis; either telephonically or onsite as needed.
- Clinical expert
Ensure provider compliance with plan standards and guidelines.
Perform ongoing education of clients, providers, medical groups and hospitals, as applicable, regarding plan benefits and alternative resources.
Serve as trainer / mentor for new case managers during their first 90 days of hire.
Participate with the approval of Manager of Health Services in the testing of new UM and CM applications.
Serve as a clinical resource for customer service representatives as appropriate.
Promote self awareness and knowledge of current medical standards in the community, recent innovations in patient care, and availability of alternative resources. Accomplish this by ongoing involvement in formal continuing education courses, review of professional publications, attendance at in-services and other relevant sources of information.
- Customer service
Provides prompt, accurate and excellent services to internal and external customers. Develops solid professional working relationships with various internal departments and units and, as required, vendors, providers, employers, brokers and/or other customers.
- General support
Participates in special projects and other duties as assigned. These may include, but are not limited to, work groups, proposals, audits and back-up support for other departments.
- Reports
Evaluation of health service utilization patterns to promote the continuing education of cost effect health utilization. Analysis of utilization and case management statistics and organization & provision of reports. Develop and maintain monthly utilization and case management reports and analysis of statistics and report conclusions to the Health Services Manager.
Knowledge, Skills, and Abilities- Knowledge of current standards of practice and available health resources within the community.
- Demonstrated objectivity and tact in the provision of assistance to members and providers.
- Ability to recognize medically necessary care versus unnecessary or inappropriate service.
- Ability to work well on own, without supervision.
- Knowledge of a variety of health care delivery settings.
- Excellent written and verbal communication skills.
- Organizational, analytical and problem solving skills.
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class