Temporary Utilization Management and Discharge Planning RN

Temporary Utilization Management and Discharge Planning RN

Salary Range : $98,601 - $147,902

The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

TEMPORARY POSITION

FLSA Status : Non-Exempt

Department : Health Services

Reports To : Health Services Management

GENERAL DESCRIPTION OF POSITION

The Utilization Management and Discharge Planning Nurse performs clinical review in accordance with applicable regulatory and professional standards for Organization Determination Requests using clinical experience and skills in a collaborative process to assess, plan, implement, coordinate and evaluate options to ensure appropriate utilization of member healthcare services and benefits for all lines-of-business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

• Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective / claims review organization determination authorization requests within regulatory turnaround requirements for all SCFHP lines of business.
• Complete authorization reviews by applying the appropriate clinical criteria / guidelines, policy, procedures and clinical judgment to render coverage determinations.
• Document pre-admission status, including living arrangements, physical and mental function, social support, durable medical equipment (DME), and other services received.
• Draft appropriate notification letters such as approval, denial, delay and modify notifications to providers and members and language threshold following regulatory requirements.
• Perform onsite concurrent review activities, as needed in the home, facility or community setting.
• Review and monitor hospital or nursing facility census and internal reports to track, reconcile and update discrepancies in member case files.
• Facilitate and coordinate communication related to post discharge with member interdisciplinary care team (ICT) including physicians, specialists, public services, community agencies and vendors to ensure care plan development and coordination of benefits and services.
• Apply the use of clinical judgment to identify and coordinate referrals to appropriate departments or programs for member identified continuity of care needs, such as Case Management, Behavioral Health, Managed Long Term Services and Supports (MLTSS), community resources, Pharmacy and Quality.
• Proactively and collaboratively interface with external case management staff including delegates to facilitate discharge planning and care transitions.
• Maintain adherence with Model of Care of CMC, LTSS and DHCS regulatory requirements.
• Facilitate appropriate processing of Letters of Agreement with non-contracted Providers for approved medically necessary services.
• Participate in new and ongoing clinical Quality Improvement initiatives.
• Perform other duties as required or assigned.

REQUIREMENTS - Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and / or ability required or desired.

WORKING CONDITIONS

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation :

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.

EOE

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