Nurse Manager - Utilization Review & Case Management
MDAEdge · Los Angeles, CA · 1 mo ago
On-siteHealthcareFull-time
Essential Responsibilities
- Assists in developing and maintaining policies and procedures for the Service Area or Medical Center related to Utilization Management.
- Collaborates with the multi-disciplinary teams to plan and coordinate care across the continuum.
- Captures care with non-KFH hospital facilities and providers.
- Identifies risk management and quality of care issues across the continuum.
- Surfaces issues and any suggestions to the appropriate multi-disciplinary team members.
- Manages transportation program to ensure appropriate utilization of resources which meet Health Plan guidelines and patient needs.
- Affirms compliance with Federal, State, TJC, NCQA, other regulatory agencies and internal standards and requirements.
- Provides direction to staff regarding utilization review, care coordination, discharge planning, and other services across the continuum of care.
- Affords assistance in conducting statistical studies in utilization trends, patterns, and outcomes.
Basic Qualifications
- Minimum three years of experience in utilization management and discharge planning in an acute care setting to also include supervisory or management experience.
- Three years of case management experience to include some supervisory or leadership experience.
- BSN or bachelor's degree in healthcare related field such as management, health services administration.
- Registered Nurse License (California).
Nice-to-Have Skills
- Certified Case Manager.
- Master's Degree a plus.
- Management experience in a union environment.
- Experience in a large hospital, high volume setting.
Additional Requirements
- Demonstrated knowledge of operations and healthcare management;
- TJC, Title XXII, Medicare, MediCal and other local, state, and federal regulations.
- Knowledge of managed care operations.
- Demonstrated interpersonal, negotiation, and management skills.
- Good oral and written communication skills.
- Must be able to work in a Labor/Management Partnership environment.