POSITION SUMMARY: Proactively conduct on-site concurrent and retro reviews of inpatient utilization according to CHCN’s clinical criteria guidelines. Implement and assist in the utilization management processes, according to departmental policies and procedures. Case Manage patients with complex post-acute care needs according to the Care Transitions model. Coordinate with clinics and outside agencies to facilitate discharge planning of patients. Responsible for denial letters required by HMO contracts and other parties.

DUTIES AND RESPONSIBILITIES • Manage and coordinate in-patient review and discharge planning and case management activities related to immediate post-discharge needs. • Train in and implement Care Transitions model in discharge planning; participate in diffusion of model in clinic setting. • Support proactive hospital discharge planning, transfers, and redirection. • Proactively and collaboratively, interface with medical director, HMO’s, clinic and facility staff, outside agencies, member and their families to assist in expediting appropriate discharge and coordination of care. • Meet departmental review and documentation standards for work assignments. • Write denial letters, and other Notices of Action, to member/providers using HMO templates. • Serve as a liaison between hospital, clinics, health plan, vendors, outside agencies, and providers. • Work with health plans on special requests such as obtaining ancillary services from non-contracting providers. • Assist UM Manager in the periodic review and update of UM/Case Management policy and procedures, and in the ongoing evaluation and improvement of workflow systems for UM. • Coordinate completion and send required UM monthly reports to Health Plans, as assigned.

QUALIFICATIONS - Competencies Desired • Competent leadership and administrative skills. • Good communication and customer relations’ skills; ability to work well with a team and independently. • Utilization Management and Case Management experience; understanding and knowledge of healthcare benefits associated with various business lines (Medi-Cal, Medicare, Commercial). • Inpatient concurrent review, especially working with complex medical patients, including aged, blind, disabled. • Ability to work independently in most instances, requiring limited supervision. • Proficiency in computer operations and comfortable with Internet-based applications. Fundamental word processing and computer navigation skills. • Sound decision-making skills including problem solving, critical thinking, and good clinical judgment for clinical and non-clinical issues. • Logical, independent thinker. • Professional demeanor.

ESSENTIAL REQUIREMENT • Active, unrestricted, California Nursing License (RN or LVN). • 2+ years in Utilization Management in hospital, HMO, or IPA setting. • 2+ years in health care delivery setting at hospital, clinic or physician’s office. • Strong understanding of the managed care environment. • Some travel required; a valid California driver’s license and proof of current auto insurance.