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UM NURSE CARE COORDINATOR
Job Field: Office Jobs
Location: Alameda, CA
Salary: $Not stated
Location: Alameda, CA
Salary: $Not stated
JOB SUMMARY:
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<tr><td valign="top" width="450"><b>UM Nurse Care CoordinatorJob ID: 2012-1253# Positions: 1Location: US-CA-AlamedaExperience (Years): 3Posted Date: 11/14/2012Category: Health Plan ServicesMore information about this job:Overview:The Utilization Management (UM) Nurse Care Coordinator is responsible for conducting the authorization and clinical review process. This position provides short term care coordination for members who are identified through the concurrent, prospective and retrospective review process. The UM Nuse Care Coordinator position involves working directly with primary and other care providers, maximizing plan benefits, using community resources, creating access, and meeting the targeted needs of the individual patient and their families.Responsibilities:PRINCIPAL RESPONSIBILITIES• Receive and review prior authorization requests for, home health, PT/OT/ST, durable medical equipment and supplies and out of area services, and non participating provider requests directing staff to communicate with providers regarding authorizations.• Timely concurrent review of inpatient admissions.• Communicate with admitting and/or the primary care physician with alternative methods to improve patient care.• Assist in coordinating discharge planning and other individual care management activities as appropriate.• Follow up telephone contact with members that present with targeted care needs post discharge, ensure communication and continuity of care with the member and other care providers.• Coordinate out of area patient transfers, organ transplant evaluation.• Initiate and manage the disenrollment of Medi-Cal members (including members assigned to Community Center Health Network, (CHCN) who are accepted for transplant (except kidney), members who require long term skilled nursing for 60 days or greater.• Initiate communication with the delegated providers, for their assigned members that are receiving inpatient and outpatient care outside of their contiguous county; and for members that reach the plan’s outlier category. Ensure weekly communications for tracking and monitoring appropriate coordination and medical management.• Identify and refer members that may be eligible to receive services from California Children’s Services (CCS), Regional Center of the East Bay (RCEB), and Local Educational Authority (LEA). Monitor and track the acceptance of those referred into these programs, working with the Director, Quality Management and Medical Services, to identify other available resources if the member is denied CCS, or RCEB services.• Problem identification and resolution in conjunction with the Health Plan Services, Medical Services and Member Services Departments to enhance the quality of patient care/satisfaction and to monitor quality of care and reduce plan liability.• Assist the Manager, Utilization and Care Coordination, in tracking and trending utilization and potential quality and potential trending indicator data, by identifying these situations in the general day to day functions of the job.• Other duties as assigned.ESSENTIAL FUNCTIONS OF THE JOB• Process authorization requests.• Timely review of inpatient admissions.• Problem identification and resolution to enhance patient care.• Coordinate discharge planning and other care management activities.• Communicate with admitting physicians re: alternative methods of patient care.PHYSICAL REQUIREMENTS• Constant and close visual work at desk or computer.• Constant sitting and working at desk.• Constant data entry using keyboard and/or mouse.• Frequent use of telephone headset.• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.• Frequent lifting of folders and other objects weighing between 0 and 30 lbs.• Frequent walking and standing.• Occasional driving of automobiles.Qualifications:EDUCATION OR
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<tr><td valign="top" width="450"><b>UM Nurse Care CoordinatorJob ID: 2012-1253# Positions: 1Location: US-CA-AlamedaExperience (Years): 3Posted Date: 11/14/2012Category: Health Plan ServicesMore information about this job:Overview:The Utilization Management (UM) Nurse Care Coordinator is responsible for conducting the authorization and clinical review process. This position provides short term care coordination for members who are identified through the concurrent, prospective and retrospective review process. The UM Nuse Care Coordinator position involves working directly with primary and other care providers, maximizing plan benefits, using community resources, creating access, and meeting the targeted needs of the individual patient and their families.Responsibilities:PRINCIPAL RESPONSIBILITIES• Receive and review prior authorization requests for, home health, PT/OT/ST, durable medical equipment and supplies and out of area services, and non participating provider requests directing staff to communicate with providers regarding authorizations.• Timely concurrent review of inpatient admissions.• Communicate with admitting and/or the primary care physician with alternative methods to improve patient care.• Assist in coordinating discharge planning and other individual care management activities as appropriate.• Follow up telephone contact with members that present with targeted care needs post discharge, ensure communication and continuity of care with the member and other care providers.• Coordinate out of area patient transfers, organ transplant evaluation.• Initiate and manage the disenrollment of Medi-Cal members (including members assigned to Community Center Health Network, (CHCN) who are accepted for transplant (except kidney), members who require long term skilled nursing for 60 days or greater.• Initiate communication with the delegated providers, for their assigned members that are receiving inpatient and outpatient care outside of their contiguous county; and for members that reach the plan’s outlier category. Ensure weekly communications for tracking and monitoring appropriate coordination and medical management.• Identify and refer members that may be eligible to receive services from California Children’s Services (CCS), Regional Center of the East Bay (RCEB), and Local Educational Authority (LEA). Monitor and track the acceptance of those referred into these programs, working with the Director, Quality Management and Medical Services, to identify other available resources if the member is denied CCS, or RCEB services.• Problem identification and resolution in conjunction with the Health Plan Services, Medical Services and Member Services Departments to enhance the quality of patient care/satisfaction and to monitor quality of care and reduce plan liability.• Assist the Manager, Utilization and Care Coordination, in tracking and trending utilization and potential quality and potential trending indicator data, by identifying these situations in the general day to day functions of the job.• Other duties as assigned.ESSENTIAL FUNCTIONS OF THE JOB• Process authorization requests.• Timely review of inpatient admissions.• Problem identification and resolution to enhance patient care.• Coordinate discharge planning and other care management activities.• Communicate with admitting physicians re: alternative methods of patient care.PHYSICAL REQUIREMENTS• Constant and close visual work at desk or computer.• Constant sitting and working at desk.• Constant data entry using keyboard and/or mouse.• Frequent use of telephone headset.• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.• Frequent lifting of folders and other objects weighing between 0 and 30 lbs.• Frequent walking and standing.• Occasional driving of automobiles.Qualifications:EDUCATION OR
KEY REQUIREMENTS:
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