83 RN Utilization Management Full Time Days Jobs in Los Angeles, CA
Martin Luther King, Jr. Community Hospital is Hiring a RN Utilization Management Full Time Days Near Los Angeles, CA
POSITION SUMMARY
The RN Utilization Management (RN UM) functions as a support liaisons for a variety of UM functions which may include: the e-TAR process, denials management, and the UM process. Coordinates care submission relating to the process of health care utilization from the point of patient admission to discharge. Assignments may also include management of the clinical denials process in collaboration with finance team. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determine medical necessity. The RN UM will complete and coordinate MCG as needed related to Observation patients including contact with insurance for authorization as needed. The RN UM ensures high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- RN Utilization Management staff may work as assigned in one of the following assignments: ETARS management and/or denials management as well as routine UM functions (insurance authorizations, clinical reviews, and liaison) :
- Daily coordination of support documents pertaining to the DNFB List of Medi-Cal patients.
- Ensures completion of patient records and attachments prior to submitting them to Medi-Cal via e-TAR.
- Assist with tracking submitted e-TARS to ensure deferrals and denials are followed-up within a timely fashion.
- Reports e-TAR support progress and delays to Manager or Director of care management.
- Participates in interdisciplinary team and department of revenue meetings to discuss e-TAR work flow, documentation necessity (attachments), process improvement, and submission timeliness.
- Identifies and reviews observation patients daily; performs concurrent MCG/electronic review for continued stay or conversion to inpatient appropriateness reviews as needed.
- Contacts insurance for pre-authorization prior to conversion; collaborates with CM RN to obtain order for admission if appropriate. Responsible for documentation of authorization information in Cerner
- Coordinates with UM Care Coordinator to transfer clinical information to payer as needed.
- Collaborates with interdisciplinary team, participants in team rounds to: (I) facilitate timely care, (2) assures quality of care throughout the hospital stay, and (3) minimizes adverse outcomes.
- Assists with the initiation of appropriate referrals to the internal interdisciplinary team and outside provider networks (health plans, IPAs, and FQHCs) as indicated.
- Communicates with admitting or PFS regarding the needs of the patient, payer, and provider documentation.
- Patient needs are supported within the limitations of the existing individual beneficiary care structure.
- Communicates relevant elements of the health plan benefits.
- Documents and reviews all team member, physician, and patient/family communications and concerns pertaining to coordination of care and services.
- Screens every patient chart to justify identified needs for assessments, documentation of medical necessity, and/or discharge planning needs if assigned.
- Adheres to the Care Management Department policies and procedures.
- Participates in the Quality and Performance Improvement Plan for the Care Management Department.
- Considers the patient population served, age-specific criteria and the Jean Watson Model of Care in all patient/family care and interaction.
- Collaborates with on-site care management team to support best practice guidelines.
- Attends unit/department staff meetings as well as other meetings as assigned.
- Maintain and complete Compass program training as assigned.
- Other duties may be assigned such as denials management and appeals in lieu of other UM duties.
A. Education
- Associates Degree in Nursing required. BSN preferred.
- Minimum 3-5 years recent experience in Case Management or Utilization Management or Prior Authorization
- Current California Registered Nurse License.
- Certification in UM or CM is highly preferred
- Experience in MCG and/or Interqual required
- A team player that can follow a system and protocol to achieve a common goal
- Highly organized and well developed oral and written communication skills
- Confidence to communicate and outreach to other community health care organizations and personnel Demonstrates sound judgment, decision making and problem solving skills
- Bilingual language skills preferred (Spanish) Basic computer skills
- Current Basic Life Support (BLS)
- CCM Certification preferred
MLKCH Video
Job Summary
Full Time
Ancillary Healthcare
$90k-109k (estimate)
03/23/2024
07/05/2024
mlkch.org
LOS ANGELES, CA
<25
2015
<$5M
Ancillary Healthcare
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About Martin Luther King, Jr. Community Hospital
Martin Luther King, Jr. Community Hospital (MLKCH) is a private, nonprofit, safety-net hospital serving 1.3 million residents in South Los Angeles. Our new hospital opened in 2015 through a unique public/private partnership with the County of Los Angeles, the University of California, and other healthcare providers. The Board of Directors of Martin Luther King, Jr. Los Angeles Healthcare Corporation (MLK-LA), which governs and operates the hospital, is committed to establishing an innovative model focused on patient-centered, coordinated care delivery, both inside and beyond the hospital wall...s. Martin Luther King, Jr. Community Hospital is licensed and accredited for 131 beds and provides general acute care. In addition to our Hope Emergency Center, which saw more than 90,000 patients in 2017, it features: - General medical-surgical services - A critical care unit - Labor and delivery services - In-house radiology - Pharmacy - Laboratory - Other ancillary services The hospital offers a level of service that ensures a high-quality, high-tech, and high-touch healthcare experience for patients and their familiesregardless of insurance status or ability to pay. At our hospital, care is organized through a state-of-the-art, safe and secure electronic health record (EHR) for each patient, and a care manager supporting the patient from admission through discharge. The care manager coordinates post-discharge care, partnering with other healthcare providers in the community to supplement the hospital-based services and provide a safe continuum of care.
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The job skills required for RN Utilization Management Full Time Days include Health Care, Basic Life Support, Collaboration, Problem Solving, Written Communication, etc. Having related job skills and expertise will give you an advantage when applying to be a RN Utilization Management Full Time Days. That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by RN Utilization Management Full Time Days. Select any job title you are interested in and start to search job requirements.
The following is the career advancement route for RN Utilization Management Full Time Days positions, which can be used as a reference in future career path planning. As a RN Utilization Management Full Time Days, it can be promoted into senior positions as a Head Nurse - CCU that are expected to handle more key tasks, people in this role will get a higher salary paid than an ordinary RN Utilization Management Full Time Days. You can explore the career advancement for a RN Utilization Management Full Time Days below and select your interested title to get hiring information.
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