- Review and evaluate proposed services utilizing medical criteria and/or established policies and procedures. This includes review of submitted medical documentation and/or photographs.
- Determine the appropriate action with regard to the service being requested for approval, modification or denial, and refer to the Medical Director for review when necessary.
- Determine if the inpatient setting requested for surgery and/or medical care is appropriate.
- Initiate contacts with patient, family, and treating physicians as needed to obtain additional information or to introduce the role of case management.
- Analyze all requests with the objective of monitoring utilization of services, which includes medical appropriateness and identification of potentially high cost, complex cases for high-level case management intervention.
- For short-term cases, conduct a thorough and objective assessment of the member’s current status including physical, psychosocial, environmental, and gather all information pertinent to the case.
- Report cost analysis, quality of care and/or quality of life improvements as measured against the case management goals.
- Routinely assess member’s status and progress; if progress is static or regressive determine reason and proactively encourage appropriate referrals.
- Prepare and maintain appropriate documentation of patient care and progress within the care plan.
- Act as an advocate in the client’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals.
- Work collaboratively with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem and solving complex cases.
- Document case notes and rationale for all decisions in the CCMS system.
- Other projects and duties as assigned.
- Current RN license to practice in the state of California is required.
- Bachelor’s degree preferred.
- 5 years minimum clinical experience with the health needs of the population served.
- Ability to work toward and/or maintain case management certification (CCM)
- ICD-9/ICD-10 and CPT coding requirements.
If you feel that you have the skills we require, please respond to this posting with your contact information and your resume in a Word document. We look forward to hearing from you today!
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