Community Health Plan of Imperial Valley (CHPIV) is Imperial County's Medi-Cal managed care plan.
We are a locally managed public health care plan committed to working with members, providers, and the residents of Imperial County.
As we continue to build something great, we are looking for a Utilization Case Manager to assess plans and coordinate optimal and timely care delivery for members along the entire continuum of care.
Our next team member will do the following:
- Monitors in-patient care and facilitates appropriate transition to out-patient or lower levels of care by referencing CHG-approved clinical criteria for utilization management decisions; reviewing member’s medical record; communicating with member, attending physician, hospital case managers and discharge planners, member’s primary care physician and other health care professionals to address member-specific needs; discussing cases with CHG’s Chief Medical Officer and Case Managers regarding appropriateness of care and alternatives; arranging home health, referral to community-based resources, and other services to meet the member’s post-discharge needs.
- Reviews inpatient census on a daily basis and prioritizes cases based on department policies, protocols, and guidelines.
- Conducts concurrent review by telephone or on-site and retrospective review by reviewing facility medical records.
- Reviews all cases that do not meet clinical criteria for utilization management decisions with the Chief Medical Officer for determination.
- Utilizes pharmacy, Emergency Room (ER) encounter history, and admission history summaries to assist providers in developing a comprehensive discharge plan which includes member’s total potential discharge needs.
- Coordinates member’s continued care needs upon discharge from inpatient setting with appropriate CHG Case Manager. Participates in Quality Improvement Activities (QIA) activities.
- Forwards quality of care concerns to the QI Department and provides case-specific follow-up for pre determined cases.
- Under the direction of department manager, researches and assists in the implementation of processes surrounding workflow and internal guideline development designed to enhance member outcomes and increase customer satisfaction.
- Attends department meetings; provides feedback for existing processes; maintains patient confidentiality; represents department in interdepartmental and external meetings and forums on request.
- Functions as a resource to internal and external customers by developing relationships with staff at assigned hospitals, clinics, and providers in order to facilitate and improve coordination of care. Provides education to members and providers on available resources. Offers assistance to peers when needed.
You may be right for this job if you have the following:
- An active California Registered Nurse License without restriction 3 years experience working in an acute care facility (ICU, emergency department, and/or medical/surgical unit) and 1 year experience in a managed care environment or hospital discharge planning or high risk management or outpatient clinic.
- Inpatient discharge planning and high risk management experience or outpatient referral management preferred.
- Working knowledge of Microsoft Word programs.
- Knowledge of managed care principles, CPT, ICD-9, HCPCS coding, experience with inpatient and outpatient medical review guidelines (Milliman USA,Interqual).Familiar with Medi-Cal, Medicare.
- Familiar with Web based standard of care sites i.e.
- NIH, ACOG.
- Ability to communicate effectively verbally and in writing; exceptional telephone and customer service skills; ability to establish effective working relationships with physicians and medical professionals; ability to organize work effectively, determine priorities, and work well independently.
Our commitment to you:
- A competitive salary of $95,800-$115,000/ year Health, dental, and vision insurance Paid time off A 401k plan with a generous match A chance to make a real difference in the Imperial Valley community This position is located on-site in Imperial, California.
- We are an equal-opportunity employer.
- We celebrate diversity and are committed to creating an inclusive environment for all employees.
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