Job description

PURPOSE
The Medical Management department is participant focused and strives to provide the best possible care for the participants through Utilization Review and Utilization Management services, Care Coordination and Outreach. The Department is designed to ensure the delivery of high-quality, cost-efficient healthcare for our participants and families through coordinating care, providing detailed discharge plans, advising participants of different programs available and providing face-to-face and telephonic education.
The purpose of this position is to ensure that the Fund’s philosophy of assisting patients to receive the best quality care in the appropriate setting is accomplished. The Hospital Care Manager is responsible for conducting utilization management activities in accordance with Utilization Management policies and procedures. While providing concurrent utilization review, the Hospital Care Manager will collaborate with the medical team and participants in the acute hospital and lower level of care settings to help guide them through the continuum of care. The Hospital Care Manger will assess, plan, implement, coordinate, monitor, and evaluate care options and services to meet our participants’ health care needs. In conjunction with the Transition Care Coordinator team, this position is responsible for ensuring that the discharge plan is achieved in a timely manner and effectively meets the patients’ needs.
ESSENTIAL JOB FUNCTIONS AND DUTIES

• Provide Utilization Review within URAC timelines and expectations
• Work with participants of all ages in the acute hospital and lower level of care settings (LTAC, SNF, Rehab) to help them through the continuum of care
• Responsible for continuous communication with all parties involved in the plan of care and decision-making to determine medical necessity and appropriateness of care for service utilization and expense
• Must follow all hospitals policies and procedures
• Daily driving within the Las Vegas Metropolitan area based upon assignment. Driving on Fund business and/or authorized to drive a Fund-owned or –leased vehicle
• Redirect care to contracted service providers per guidelines
• Daily communication with attending physicians regarding treatment and discharge planning needs
• Participate in weekly Medical Rounds with Medical Director and team
• Provide the necessary interventions to assure effective and efficient discharge planning
• Research patient issues, barriers to care and report findings to management
• Coordinate and attend family conferences for difficult discharge planning i.e., hospice, long term care, non-compliance
• In conjunction with the hospital staff, coordinate hospital to hospital transfers
• Maintain comprehensive, accurate and up-to-date record of patient care
• Identify delays in care and send to physician reviewer for medical necessity review
• Identify quality issues and refer to the Quality Committee for review
• Assist management in development of protocols and procedures as they relate to UM/CM
• Assist with on boarding and training new staff
• Participate in the weekend on call rotation
• Perform benefit education to participants and providers
• Sets goals and achieve measurable results
• Contributes ideas to plans and achieving department goals
• Demonstrates the Fund’s Diversity and Inclusion (D&I) principles in their conduct at work and contributes to a safe inclusive culture with equitable opportunities for success and career growth
• Exemplifies the Fund’s BETTER Values in contributing to a respectful, trusting, and engaged culture of diversity and inclusion
• Performs other duties as assigned within the scope of responsibilities and requirements of the job
• Performs Essential Job Functions and Duties with or without reasonable accommodation

ESSENTIAL QUALIFICATIONS
***MUST BE FULLY VACCINATED AGAINST COVID19***
Years of Experience and Knowledge

• Minimum 3 years’ experience in a hospital environment or equivalent required
• Experience with Case Management and Managed Care preferred

• *Education, Licenses, and Certifications

• Associate's degree in Nursing required
• Preferred: Bachelor’s degree in Nursing
• Required: Valid, unrestricted state driver’s license
• Personal vehicle registration and insurance
• Unrestricted active RN License in the State of Nevada
• Preferred: CCM certification
• Willingness and ability to obtain a license in other States as may be required by the Fund

Skills and Abilities

• Microsoft Office skills (PowerPoint, Word, Outlook)
• Microsoft Excel skills
• Preferred fluency (speak and write) in Spanish
• Excellent written and verbal communication skills
• Excellent interpersonal skills – ability to express compassion and balance the emotions with business needs
• Strong analytical skills
• Communicate clinical information to non-clinical individuals
• Manage competing deadlines and multiple projects in a fast-paced environment

Job Type: Full-time

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