Registered Nurse /Utilization Care Manager Job in El Dorado Hills, CA

Location: El Dorado Hills
Posted on: October 24, 2024

Job Description:

 
Modis is looking to fill a Nursing/Utilization Care Manager contract with likelihood to extend, with our healthcare client in El Dorado Hills, CA. If you meet the below requirements and would like to learn more about this great opportunity please apply now for immediate consideration.
 
We are looking for a Nurse/Case Manager familiar with performing advanced or complicated case review and determining first level approvals for prior authorization of services, inpatient, outpatient and/or ancillary services. You will act as liaison between the member, the provider and the health plan to utilize appropriate and cost effective resources. Ultimate goal is Discharge (DC) planning and to return patient to cognitive and physical condition prior to event that triggered treatment.
 
EXPERIENCE

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• Requires extensive experience in nursing, 2-3 years acute clinical experience and 3 years utilization management preferred
• Computer proficiency, Microsoft Office, Outlook, Excel, Word

 
RESPONSIBILITIES

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• Performs prospective, concurrent and retrospective utilization reviews and first level determination approvals for members
• Determines discharge (DC) plan by assessing cognitive and physical status. Determines post-acute needs of patient, levels of care
• Triages and prioritizes cases to meet required turn-around times. Expedites access to appropriate care for members with urgent needs using expedited review process.
• Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.

 
QUALIFICATIONS/ JOB REQUIREMENTS

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• Current active CA RN License required. Bachelors of Science Degree in Nursing preferred.
• Proficient knowledge of NCQA, URAC, federal and state requirements
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable.
• Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care.

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