***This position is work from home within California.

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups hospitals health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options including medical dental and vision plans for the employee and their dependents Health Spending Account (HSA) Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

***This position is work from home within California.

Position Summary:

The Out-of-Network Utilization Management RN is responsible for improving care management coordination between SSJSA hospital staff and affiliated medical groups and IPA’s by using advanced problem-solving skills, consultation, communication, personal education, and research. This position is also responsible for providing oversight for out-of-network (OON) cases that are capitated to the Dignity Health hospitals in the GSSJSA and to provide support to the Director Clinical Partnerships related to managing GSSJSA capitated business. This position works with affiliated GSSJSA Medical Groups and IPA’s to meet appropriate quality patient satisfaction and utilization objectives in a manner consistent with the Mission and Philosophy of Dignity Health.

Responsibilities may include:- Locate and coordinate care for Dignity Health members who are in the Emergency room or hospitalized inpatients outside the Dignity Health system.- Locate and coordinate resources for members who are returning to the Dignity Health system (repatriation).- Coordinate care on complex cases where hospital and/or medical group are at risk.- Measure performance of case management for the high risk and high opportunity patients.- Identifies complex/problematic system issues related to care management and involves the multidisciplinary team to improve quality and appropriate resource allocation.- Provide monthly and or quarterly reports related to out of network (OON) utilization with comparison to objectives for all affiliated medical groups. Share monthly and/or quarterly reports related to OON utilization with appropriate affiliated medical groups and as appropriate interact with Joint Operating Committees to meet objectives.- In collaboration with the Director, Clinical Partnerships, develops and implements programs to enhance the quality and profit margins of the organization.- Focuses on high volume, high risk patient populations and/or DRG groups to identify opportunities to improve patient outcomes and reduce unnecessary resource utilization.- Accurately communicates with providers about the diagnosis and severity of illness to determine appropriate levels of care.- Coordinates transfers via Dignity Health transfer center of out of network capitated patients to the appropriate level of care.- Coordinates concurrent review for patients at non- Dignity Health facilities with affiliated medical groups to reduce out of network expenses for Dignity Health.- Assists in verifying case data for each facility to provide correct medical group risk payment and prevent discrepancies.

Minimum Qualifications:

- Five (5) years experience in utilization review and discharge planning, case management and managed care. JCAHO and State and Federal Regulations. Coding, documentation, DRG’s. Case Management models and standards. Nursing theory and practice standards. Research models. Continuous quality improvement methods. Knowledge of reimbursement under Medicare, MediCal and private insurance, Capitation including Medical group/physician implication. Case management of capitated at-risk patients. Knowledge of the meeting process.- Clear and current CA Registered Nurse (RN) license.- Bachelors in nursing, business or equivalent or a combination of knowledge and experience.- Special skills:Self-starter and works independently. Organizational and management skills. Qualitative data collection methodologies and analytical analysis. Problem solving skills. Effective interpersonal communication skills. Interpret contracts for benefit analysis as appropriate. Must have excellent interpersonal skills to effectively build relationships within and outside the organization.

Preferred Qualifications:

- Certification in Case Management (CCM) preferred.