Address
Form of work
SalaryHours
Shift Start Time:
Shift End Time:
4:30 PMAdditional Shift Information:
Weekend Requirements:
No WeekendsOn-Call Required:
NoHourly Pay Range (Minimum - Midpoint - Maximum):
$31.495 - $40.639 - $49.783
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 Do
To provide comprehensive utilization management and coordination of care for SRS Members. Ensure timely and appropriate processing of managed care referrals to meet specific healthcare criteria in a cost-effective manner utilizing available resources.
Required Qualifications
- 3 Years experience in the acute patient care, Home Health and/or SNF setting.
- 2 Years Utilization/Case Management experience, preferably in a Managed Care setting.
- California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians -REQUIRED
Preferred Qualifications
- Experience as a case manager or discharge planner interacting with managed care payers.
Other Qualification Requirements
- California Licensed Vocational Nurse (LVN)-License must be unrestricted.
Essential Functions
- Referral Coordination
Ensures consistent application of the Utilization Review process for effective utilization of resources.
Identify when services that are not medically necessary and/or not covered benefit and refer to Utilization Review Committee. Ensures that all denials for medical necessity are issued under the direction of the Medical Director or designee. - Data and documentation collection
Gather relevant, comprehensive information and data according to specifications.
Complete comprehensive medical record review to gather information.
Communicate effectively with providers and healthcare personnel to obtain data required for decision making. - Act as a Resource
Demonstrates knowledge of Health Plan contracts and Health Plan benefits. Coordinates services and supplies through SRS (or health plan) contracted vendors.
Collaborates with referring physicians, providers or vendors.
Assists coworkers and clinics as necessary.
Advocates both for client and payer.
Identify cost-effective, appropriate alternatives.
Contribute as a managed care resource and educate other healthcare members of referral process. - Quality of Work
Ensure high volume of referrals are processed accurately in a timely manner.
Practice in accordance with applicable local, state and federal laws.
Maintain knowledge and understanding of applicable accreditation and regulatory statutes.
Accurately identifies the criteria to utilize based on Health Plan Hierarchy.
Promote most effective and efficient use of healthcare services and financial resources. - Identification of Opportunities/Problem Resolution
Identify opportunities for intervention which may include identification of patterns/trends: use of inappropriate services, utilization of services/providers.
Communicates opportunities to Leadership.
Communicate and collaborate effectively with healthcare team.
Engages problem-solving skills in order to reconcile differing points of view.
Actively promotes/coordinates and facilitates communication among the healthcare team members, the payer and other relevant parties.
Knowledge, Skills, and Abilities
- Basic ICD and CPT coding knowledge.
- Working knowledge of computer programs (Word and Excel).
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
