Case Manager III, Ambulatory ( RN )
Job Description
Assesses utilization of resources to ensure cost effective care using evidence based criteria.
Maintains Utilization Review Accuracy rate of 90% and meets productivity standards.
Performs comprehensive chart review and utilizes InterQual criteria for potential and actual admissions, continued stay and/or retrospective reviews to determine appropriateness of the admission, setting, continued services, and level of care.
Initiates timely communication with case managers, physicians, other staff and leaders when medical necessity deficiencies and denials trends are identified.
Identifies and collaborates with Sutter Health on new approaches and best practice models for denials prevention.
Monitors appropriate reports for admissions and/or continued stays requiring Utilization Review.
Maintains current knowledge base of regulatory laws, insurance contracts, coverage and reimbursement rules for Medicare, Medi-Cal and other government and commercial payers.
Provides training, peer reviews, quality assurance and support.
Provides hands-on training, education and support to new hire and staff RN case managers, as required.
Assists Care Coordination Educators with training and development activities.
Considers adult learning styles and development levels and tailors educational approach and methods accordingly.
Provides feedback and assesses case manager progress and compliance with established Sutter Utilization Management (UM) Process and Case Management (CM) workflows.
Conducts InterQual and chart audits to assist with peer reviews.
Provides audit results, trends and significant developments related to resource or utilization management.
Acts as a liaison to departments for management of claims to support adjudication of all capitated claims, including acute enrollee notification submissions.
Attends weekly conference calls with other departments to review claims for payment versus denial.
Conducts daily reviews and provides case management for all capitated inpatients.
Coordinates follow-up and outpatient care with capitated members’ medical group.
Assists with coordination of second level review authorizations.
Education & Certification
Graduate of an accredited school of nursing.
Certification & Licensure: RN-Registered Nurse of California.
Experience
5 years recent relevant experience.
Skills & Knowledge
Broad knowledge base of health care delivery and case management within a managed care environment.
Knowledge of utilization review process, OIG, CMS, RAC, and all other regulatory agencies related to utilization management.
Comprehensive knowledge of medical necessity standards, levels of care, inpatient and outpatient status (observation, ambulatory procedure, emergency).
Verbal and written communication skills.
Able to work with team members to produce desired goals and objectives.
Able to successfully navigate multiple computer programs for chart review, medical necessity determination, and care coordination processes.
Able to provide group and one-on-one education to new hires and peers.
Proficient in Excel spreadsheets, use of pivot tables, formulas and graphs.
Proficient in Microsoft suite including Word and Outlook.
Physical Activities & Requirements
See required physical demands, mental components, visual activities & working conditions at the following link.
Job Requirements
Demonstrates a clear understanding of, and consistently adheres to System, department and facility policies, procedures and standards.
Attends and actively participates in department and facility meetings, training and classes, including annual fire, safety, and disaster programs.
Benefits
Yes
Unions
No
Position Status
Non-Exempt
Weekly Hours
40
Employee Status
Regular
Pay Range
$90.58 to $126.81 / hour
Total Compensation
The compensation range may vary based on the geographic location where the position is filled. Total compensation considers multiple factors, including, but not limited to a candidate’s experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs.
Base Pay
Base pay is only one component of Sutter Health’s comprehensive total rewards program.
Eligible Positions
Includes a comprehensive benefits package.