Disease Management Case Manager jobs in Anaheim, CA

POSITION SUMMARY:

To ensure coordination of timely and appropriate care for all hospitalized members; To ensure the delivery of cost-efficient, appropriate health care services for all members; To ensure members with complex and chronic care needs are addressed; To ensure plan for coordination among all disciplines; To ensure that medically necessary care is delivered for members that require extensive on-going service; Identification of any potential quality issues.

EDUCATION & EXPERIENCE REQUIREMENTS:

• Licensed Vocational or Registered Nurse with valid California Nursing License.
• Experience in telephonic concurrent review process.
• Experience in Case Management in hospital, IPA or managed care environment.
• Knowledge of medical criteria for length of stay and/or experience with Milliman and/or Interqual Healthcare Guidelines.
• Basic computer data entry experience.
• Knowledge of CPT/ ICD-10 coding.

ACCOUNTABILITY/DUTIES/RESPONSIBILITIES:

• Maintain compliance with UM Plan and Policies and Procedures as related to your role of Nurse, Case Manager.
• Coordinate daily Concurrent Review activity for assigned IPAs/Medical Groups, by coordinating with Hospital Case Managers, Health Plans, Primary Care Physicians, Medical Director, Hospitalists, etc.
• Identify Estimated Length of Stay and necessity using Apollo, Interqual and/or Milliman Healthcare Guidelines.
• Ensure review appropriateness (IP criteria met) of admission within 24-hours of notification
• Coordinate and ensure timely discharge planning with appropriate contracted ancillary providers.
• Identify Potential CCS Eligible conditions and coordinate with CCS Coordinator. Assist with obtaining CCS authorization and logging in system.
• Identify and refer cases for outpatient Case Management using criteria and support activities.
• Develop and maintain professional working relationships with Medical Directors, facilities, vendors and all Providers within the contracted IPAs.
• Ensure documentation of denial of service. Ensure denial letter is sent within 24 hours of the denial decision.
• Report any potential quality issues immediately to VP UM, In-Patient and Out-Patient Services and IPA Medical Director.
• Document clearly and appropriately all case related activity daily in EHC to include updates discharge plan.
• Maintain compliance with HIPAA rules and regulations.
• Attend Concurrent Review clinical rounds as scheduled and as requested by Concurrent Review Manger and/or VP UM. (Outliers > 5 days and Discharge barriers)
• Maintain current California Nursing license.
• Other duties, as assigned.

WORK ENVIRONMENT, PHYSICAL DEMANDS AND MENTAL DEMANDS:

1. Typical office environment with no unusual hazards.

2. Repetitive movements with use of keyboard, mouse, and phone.

3. Constant sitting while using the computer terminal.

4. Constant use of sight abilities while reviewing documents.

5. Regularly speak and listen in person, telephone, and remote meetings

6. Constant mental alertness must possess planning/organizing skills and must be able to work under deadlines.

7. Occasionally required to stand, walk, stoop, kneel, bend, crouch and lift up to but not more than 10 pounds.

If you are passionate about providing quality healthcare services and possess the necessary skills and experience, we encourage you to apply for this rewarding position. Join our team today!

This employer participates in E-Verify and will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the U.S.

Job Type: Full-time

Pay: $60,320.00 - $74,880.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Ability to Relocate:

• Cypress, CA 90630: Relocate before starting work (Required)

Work Location: In person