Job Opportunity Details

Job ID Specialty Geographic Location City State Recruiter
2230474 Case Manager 20.9 miles North of Fairfield Napa CA The Clinical Recruiter

Company Name: The Clinical Recruiter
Recruiter Name: Chris Monroe
Contact Phone: 615-547-2432

Job Title: Case Manager RN - Utilization Review

In HouseID:

Job Description

This is a Case Manager Opportunity Only!

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20.9 miles North of Fairfield    (Only QUALIFIED Healthcare Professionals accepted) Case Manager - Case Manager RN - Utilization Review
Napa | Napa, California
JO# 22977 
General Summary:
The Case Manager assumes 24-hour responsibility and assists with the direction, management, and evaluation of the Case Management|Social Work departments.
·         Reports to the Director of Case Management and assists with clinical, operational, and financial aspects of the Case Management|Social Work departments.
·         Manages all aspects of Case Management and Utilization Management, including admission and continued stay medical necessity reviews, payer authorization, discharge planning, denials management, and ensures adherence to the case management plan.
·         Assists with hiring, training, directing, development and evaluating of staff.
·         Assists with development of action plans, and may report outcomes to the Case Management Director, CNO, or others as applicable.
·         Assists with the design, implementation, training, and resources for the Case Management system for the organization.
·         Evaluates personnel, assesses environment, and determines priorities for care in order to plan, implement, and evaluate outcomes of care. 
·         Evaluates the effectiveness of existing clinical protocols and pathways and makes recommendations for new ones.
·         Works effectively with MCO staff and leadership to decrease denials or downgrades in reimbursement.
·         Ensures collaboration among health care providers across the Continuum of Care to maximize effective access and efficient utilization of resources.
·         3+ years Case Management experience required
·         2+ years nursing supervisory|management experience in acute care required
·         Managed Care Organization (MCO) experience preferred
·         Bachelor of Science in Nursing (BSN) required
·         Master’s Degree in Nursing or related preferred
·         Registered Nurse License required
·         Certified Case Manager (CCM) highly desired
·         Healthcare Quality of Utilization Review (HQUR) a plus
Special Skills: 
·         Must be able to use independent decision-making skills in a wide variety of situations
·         Frequent contact with employees, physicians, customers, community individuals and volunteers
·         Must be self-motivated to complete work in a timely manner to meet deadlines
·         Experience with Core Measures, Quality Indicators, Case Management, and Utilization
·         Knowledge base of InterQual criteria
·         Knowledge of Managed care trends, Medicare, and Medicaid regulations
·         Advanced negotiation and mediation skills


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