Utilization Management Complex Case Mgr Job at Northbay Healthcare
Northbay Healthcare Fairfield, CA 94533
At NorthBay Health the Utilization Management (UM) Case Manager (CM) is to assess, plan, implement, monitor and evaluate options and services to affect an appropriate, individualized plan for the patient across the continuum of care. Using independent judgment and discretion, the continuum must be reassessed as an ongoing process for the individual being served by the UM CM. This is applied to multiple environments and interactive with the relative components of the patient’s health care system. The process addresses the individual’s broad spectrum of needs. The UM CM utilizes clinical knowledge and competence, positive communication skills, problem solving and conflict resolution techniques, ability to effect change, strong skills in assessment, organization, and time management. The case management process requires a focus on customer service skills, knowledge of setting appropriate goals and measuring outcomes to effectively ensure optimal client outcomes with consideration to payer requirements.
The UM CM works under the direction of the Manager of UM/AVP of Care Coordination. The UM CM works across the healthcare continuum encompassing the NorthBay HealthCare System, network and out of network services in collaboration with patients/families, physicians, staff and administration to ensure appropriate care at the appropriate level to high-risk member
JOB SPECIFICATIONS
Education:
- Graduated from an accredited nursing school or college. BSN required.
- Masters prepared in nursing or other health related field preferred.
Licensure/Certification
- Current California state RN license required Certified Case Manager (CCM) or Accredited Case Manager (ACM) within one year of starting the job.
Experience:
- Minimum of 2 years relevant clinical experience required.
- Minimum of 1 year case management experience preferred; equivelent case management education will be considered
Skills:
- Knowledge of personal computer with experience entering and retrieving data and MS Suite software specifically MS Word processing and/or good keyboard skills required.
- Ability to effectively communicate with all levels of patients, physicians, health care personnel, supervisory staff, and peers.
- Demonstrates the exceptional ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.
- Demonstrates the willingness to research, learn, and obtain knowledge for the performance of the position.
- Demonstrates a courteous, professional demeanor at all times either working individually or in a team environment working collaboratively in an effective manner maintaining positive relationships with peers and supervisors alike.
- Utilizes critical thinking, and applies sound clinical judgment and assessment skills for decision making.
NorthBay Way Standards:
The NorthBay Way is a set of value-based behaviors that are to be consistently demonstrated and role modeled by all employees that work at NorthBay Healthcare. The NorthBay Way principles consist of Caring, Communication, Collaboration, and Competence.
Knowledge of:
- NCQA, DHS, CMS, JCAHO and EMTALA standards and federal and state regulations.
- Acute care, home care, subacute care, long-term care, hospice interventions, rehabilitation options, other community resources and requirements.
- Millimann, Interqual medical necessity guidelines.
- Expert knowledge of CPT and HCPC codes and related guidelines.
- Expert knowledge of ICE guidelines governing TAT, claims and the denial process.
- Current standards and trends in health care, best practices, management tools, and familiarity with related resources and literature.
- Capital and Managed Care legislation.
- CMSA Standards of Practice
Compensation: Hourly salary range MIN$71.34 - MAX $86.08 (offered hourly rate based on experience)
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