· Working with complex cases promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits.
· Works with other members of HCS team, provider, hospitals, members and their families to plan and review medical necessity, intensity of services, level of care, length of stay and general appropriateness of care.
· Provides guidance to the provider network.
· Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care.
· May provide referrals for case management to member segments with chronic illness i.e., disease management, Quality Management and Appeals and Grievance Department.
· Discharge planning for cases that exceed Extension of Authority or dx assigned to RN.
· Coordinates Care for Lower Level of Care coordination such as Skilled Nursing Facility, Home Health, Home Infusion, Rehab.
· Ability encompasses broad knowledge of concepts, practices and procedures required within health care field.
· Uses concepts and abilities as well as internal policies and procedures to complete assignments and solve problems
· Reviews cases for Continuity of Care and invest/exp requests
· Support to senior/lead CMs as needed.
Job Requirements:
Qualifications:
· State of California RN Licensure
· BSN Degree or higher
· Minimum 3 years clinical nurse practice, higher than Med/Surg.
· Minimum 2 years of Managed Care (Utilization or Case Management)
As an equal opportunity employer, ICONMA prides itself on creating an employment environment that supports and encourages the abilities of all persons regardless of race, color, gender, age, sexual orientation, citizenship, or disability.