Utilization Mgmt and Coordination Nurse

The Judge Group
Published
August 28, 2021
Location
La Palma, CA
Category
Job Type

Description

Location: La Palma, CA
Description: Judge is currently sourcing for an LPN /LVN licensed in California for Utilization Mgmt. to coordinate in network and out of network events.  

Synopsis:

Currently, the role is fully remote - work from home, but could switch back to an in the office role  depending on how the Covid-19 pandemic plays out. 
Either way, the role is fully telephonic and does not involve direct patient contact. 
Job Duties:

  • Directly performs concurrent review.
  • Accurately identifies and documents level of care.
  • Coordinates, facilitates and documents comprehensive discharge planning.
  • Coordinates in-network services for OON discharges.
  • Ensures the appropriate utilization of capitated and contracted specialists, providers, facilities, and vendors according to region and risk.
  • Attends inpatient review rounds and presents cases to medical director(s), health plans and management staff
  • Facilitates OON transfers to In-Network facilities.
  • Works collaboratively with internal and hospital contract staff.
  • Initiates letter of agreement for OON services in a timely manner.
  • Provides input for potential contracts.
  • Identifies and communicates high dollar / high risk cases
  • Oversees the utilization of contracted facilities and reports OON utilization.
  • Develops and maintains relationships with both network and Out of Network hospital UM and ER staff.
Additional Duties:
  • Works directly with site Hospitalists to develop and implements inpatient processes including, but not limited to:
  • Identification of patients and referral to specialty clinics such as Comprehensive Care (high-risk) Clinic, Anti-coagulation and/or Diabetic Clinic.
  • Facilitates and ensures timely communication between PCP and Hospitalists.
  • Provides direct Case Management activities if necessary.
  • Identifies readmit for CM coordination.
  • Identifies Healthy Families and Medi-Cal members for CCS referral and facilitates those referrals
  • Identifies and coordinates high dollar/high risk patients to case management.
  • Participates in UMC/QIC, PCP, Provider Office Meetings, health plan JOMs, and hospital JOCs as assigned.
  • Participates in inpatient UM/QM projects and completes in a thorough and timely manner.
  • Other duties as assigned which may include weeknight, weekend, and holiday on-call.
Education and Skills:

High School or GED - 
LPN / LVN license in California -unencumbered and active.
Excellent documentation and interpersonal skills a must have.
EMR experience 
Please email resumes to me at [Click Here to Email Your Resumé] or text inquires to (484) 585-4078.
I look forward to chatting with you soon. 
Kind regards,
Matt Mabry 

Contact: [Click Here to Email Your Resumé]

This job and many more are available through The Judge Group. Find us on the web at www.judge.com
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