Providence is calling a Ambulatory Case Manager ( Full Time / Day Shift ) to our Facey Utilization Management location in Mission Hills, CA.
In this position you will:
- Ambulatory Case Manager reviews ambulatory referrals on all capitated patients.
- The referrals are evaluated for medical necessity using clinical guidelines.
- Appropriate targets are selected using the Select Provider List, Contract information, and awareness of division of financial responsibility.
- The case manager works closely with the UM Medical Director and UM Assistant Medical Director to ensure that decisions are consistent with guidelines.
- The ambulatory nurse case manager prepares cases for weekly UM committee and Clinical Case reviews at several Providence Health & Services sites.
- Works closely with the Gerinet SNF team to deliver appropriate skilled care at the nursing home level.
- Assists the UM Compliance Manager in preparing for health plan audits and ensuring that all referrals are evaluated within the appropriate time frames.
- Is a resource to Providence Health & Services physicians and Nurse Practitioners.
Required qualifications for these positions:
- RN graduate of an accredited school of nursing required.
- Strong clinical background preferably in acute care or home health.
- Current California RN license
- American Heart Association BLS for Health Care Providers .
- Must possess excellent customer service and communication skills.
- Must be organized and a self-starter, be able to utilize multiple resources to determine health plan requirements and benefits as applied to the utilization and case management process and clinical decision making.
- Must have working understanding of MS Outlook, Word and Excel and be capable of being trained in referral processing software.
Preferred qualifications for these positions:
- Bachelor's degree
- Three to five years experience in a managed care setting/utilization review/discharge planning/case management.
- Experience as an RN with Ambulatory Case Management.
- Strong knowledge of Managed Care Plans.
About the organization you will serve:
Facey is a Medical Group with offices in the San Fernando, Santa Clarita, Simi and San Gabriel Valleys. We are known as a multi specialty medical group, meaning we employ over 180 healthcare providers offering a broad range of specialties including primary care, OB/GYN and medical and surgical specialties. Facey operates two Urgent Care Centers (Santa Clarita & Mission Hills) that offer comprehensive physician services, lab and radiology seven days a week. We have affiliations with several hospitals in our service areas including Providence Holy Cross Medical Center, Providence St. Joseph Medical Center, Henry Mayo Newhall Medical Center, Northridge Medical Center, Simi Valley Medical Center and San Gabriel Medical Center. We are physicians who treat members of various insurance plans. Facey contracts with most of the major health insurance plans. We see HMO, PPO, Medicare, MediCal and cash pay patients. For those who are Medicare eligible, Facey not only takes Medicare but we contract with many of the Medicare Advantage Prescription Drug Plans (MAPD – HMO) as well as Medicare Supplement or MediGap PlansHigh School.
We offer a full comprehensive range of benefits - see our website for details
As people of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.
Providence Health & Services is the third largest not-for-profit health system in the United States. Providence employs more than 82,000 caregivers (employees) across a five-state area; AK, WA, MT, OR, and CA. Our facilities include 34 hospitals, 600 physician clinics, senior services, supportive housing and other health and educational services. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Case Management
Location: California-Mission Hills
Req ID: 147865