The incumbent serves as the Bay Area Operating Unit Case Manager (CM) Subject Matter Expert (SME) performing Case management roles and functions, with a primary focus on InterQual medical necessity reviews, training newly hired team members, quality assurance and support. Additional training may also include discharge planning for newly hired staff. Incumbent must consistently maintain System accuracy and productivity standards.
Incumbent must have the ability to conduct group and one-on-one training sessions with peers and new hire RN case managers, provide constructive feedback, and assess progress and compliance with the System standardized UM Process and CM workflows. Incumbent must also have the ability to schedule RN Case Manager training sessions, conduct and present audit findings, trends and program results to staff and leaders.
The incumbent works with Bay Area Care Coordination Educators as needed, and may be responsible for adjudicating managed care acute enrollees as assigned by the Director. The incumbent may have contact with patients, families, the interdisciplinary team, nursing management, quality and ancillary services, third party payers and review agencies. The incumbent must develop key relationships with Case Managers, Care Coordination leaders, and Physician Advisors, in addition to maintaining a beneficial working relationship with team members and physician leaders to assist in the clinical review process. Qualifications:
Education/Certification/Licensure (enter the degree or certification, registration, licensure type in the appropriate box)
MS in Case Management or related field
National Certification in Case Management (ACM, ANA RN-BC Case Management)
or Equivalent Ed/Exp
Experience (number of years and type of work experience/environment needed to be fully proficient in the job. This should reflect the minimum requirement, unless noted as preferred).
- Minimum of three (3) years in acute medical-surgical nursing, emergency department or critical care required. Masters of Nursing in Case Management in lieu of three (3) years in acute medical-surgical, emergency department or critical care nursing may be considered for employment at the Director’s discretion.
- Previous Case Management experience preferred.
- Experience with providing training, education or as a preceptor preferred.
- Experience utilizing electronic health records preferred.
- Experience with Midas preferred.
- Experience with InterQual or other standardized medical necessity criteria preferred.
- Experience in clinical denials management preferred.
Knowledge (information gained through education or experience that incumbent would draw upon to perform this job. This should reflect the minimum requirement, unless noted as preferred).
- Broad knowledge base of health care delivery and case management within a managed care environment.
- Knowledge of utilization review process, OIG, CMS, RAC, and all other regulatory agencies related to utilization management.
- Comprehensive knowledge of medical necessity standards, levels of care, inpatient and outpatient status (observation, ambulatory procedure, emergency).
Skills (technical/physical abilities acquired through education or experience that incumbent would use in this job. This should reflect the minimum requirement, unless noted as preferred).
- Excellent verbal and written communication skills.
- Able to work with team members to produce desired goals and objectives.
- Able to successfully navigate multiple computer programs for chart review, medical necessity determination, and care coordination processes.
- Able to provide group and one-on-one education to new hires and peers.
- Proficient in Excel spreadsheets, use of pivot tables, formulas and graphs.
- Proficient in Microsoft Outlook.
- As required, travel to locations within the Bay Area Operating Unit
Organization: California Pacific Medical Center
Employee Status: Regular
Employee Referral Bonus: No
Position Status: Non-Exempt
Job Shift: Day
Shift Hours: 8 Hour Shift
Days of the Week Scheduled: Varied Days
Weekend Requirements: Rotating
Schedule: Part Time
Hrs Per 2wk Pay Period: 64.00
All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity, or expression, ancestry, national origin, age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy, childbirth or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.