RN/Case Management Nurse

Quality Care Starts At Clinicas!

This is an excellent opportunity to work for an organization that truly makes a difference in the community. Clinicas Del Camino Real, Inc.

offers a highly competitive salary; excellent benefit package including full medical, dental, vision, life and disability insurance;

generous holiday, vacation and sick leave.

Essential Duties and Responsibilities

CM Nurse’s responsibilities include, but are not limited to :

• Conduct clinical review for inpatient, out-patient and ancillary services requests for medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans.
• Review, triage, and prioritize authorization requests to meet required turn-around times.
• Expedite access to appropriate care for members with urgent or immediate needs using the expedited review process.
• Perform research and analyze complex issues, assesses member needs.
• Acquire appropriate clinical records, clinical guidelines, policies, EOC and Benefit Policy.
• Accurately applies coding guidelines.
• Identify appropriate health care resources based on member's medical needs, including but not limited to evaluating contracts and negotiating with facilities / vendors.
• Using professional judgment, independent analysis and critical-thinking skills, applies clinical guidelines, policies, benefit plans, etc. to case review.
• UM / CM case summarization including analysis of medical records and appropriate application of all applicable policies, guidelines and benefit plans.
• Makes first level approval determinations when request meets appropriateness, medical necessity and benefit criteria.
• Develop determination recommendations and present cases to Medical Director (or designee) for potential denial determinations or when Medical Director input is needed.
• Interact with the providers or members as appropriate to communicate determination outcomes in compliance with state, federal and accreditation requirements.
• Develop and / or review appropriate documentation and correspondence reflecting determination. Ensures documentation is accurate, complete and conforms to established regulatory standards.
• Document all activities as per unit practice including entry into automated systems. Recognizes potential quality care concerns and refers as appropriate.
• Make appropriate referrals to California Children’s Services (CCS) and Tri Counties Regional Center (TCRC).
• Identify and refer members who may benefit from disease management or case management and make appropriate referrals.
• Identifies potential TPL / COB cases, investigates TPL / COB issues, and notifies the appropriate internal departments.
• Manages out of area cases / requests based on current policy and refers them to the primary insurer as appropriate.
• Conducts rate negotiation, when necessary and as per policy, with non-network providers, utilizing appropriate reimbursement methodologies.
• Documents rate negotiation accurately for proper claims adjudication.
• Coordinate UM / CM review activities with contracted and / or delegated entities, as needed.
• Attend meetings as assigned.
• Meet with staff at various health centers as assigned.
• Perform additional duties as assigned.

Education :

• Graduate of an accredited nursing program required (e.g. ASN, ADN, BSN,MSN).
• Bachelor's degree preferred.

Certification / License :

• Active, valid, & unrestricted State of California Registered Nurse license is required.
• UM / CM certification preferred.
• Clean California Driver’s License and automobile insurance is required.
16 days ago