Providence Health & Services RN - Case Manager PPO in Mission Hills, California
Providence is calling a RN - PPO Case Management ( Full Time / Day Shift ) to our Providence Facey Medical Foundation PPO Department located in Mission Hills, CA.
In this position you will be responsible for providing:
Works under the direction of the Director of Case Management with the PHSCA Medical Group providers and patients to support and expedite urgently and routine services needing Health Plan prior authorization or disposition to the most efficient network facility taking preference for PHSCA facilities and providers.
Assures submission of all prior auths to payors contains appropriate clinical information in order for plan/payer to review and make decision in a timely manner.
Is a resource to the Payor/Health plan PPO ambulatory nurses ensuring that appropriate clinical information and other needs are met to expedite care.
Understands the proper escalation of circumstances resulting in barriers to care for our PHSCA patients.
Ensures that cases where avoidable delays are encountered are appropriately evaluated by the CM Director and where necessary, the MG UM Medical Director.
Works with the CM Director to understand denial accuracy, denial timeliness, personal productivity, completion of documentation to support decision in IDX including guidelines and references cited.
Works with Health Plan PPO Ambulatory Nurse Case Managers to develop and maintain constructive working relationships with providers, health plans and regulatory agencies.
Works with staff to treat each other with respect and professionalism as defined in our guiding Mission and Values.
Required Qualifications for this position include:
RN graduate of an accredited school of nursing.
Current California RN license
American Heart Association BLS for Health Care Providers.
Must possess excellent customer service and communication skills.
Must be organized and a self‑starter.
Must have extensive knowledge of health plan requirements and benefits as applied to the utilization and case management process and clinical decision making.
Must have working understanding of MS Outlook, Word and Excel and be capable of being trained in referral processing software.
Needs to be able to access and applyall appropriate clinical guidelines approved by Health Plan, Medicare / MediCal or other payor resourceto patient cases requiring prior authorization.
Needs to be aware of Health Plan criteria regarding timeliness of referrals, denial rationale and denial language.
Must possess strong oral and written communication skills, problem solving and analytical skills as related to Utilization Management.
Preferred Qualifications for this position include:
- Three to Five years’ experience preferred in a managed care setting/utilization review/discharge planning/case management of which two years is in hospital or ambulatory case management.
About the organization you will serve:
Facey Medical Group is a multi-specialty medical group with over 160 physicians providing care to the growing population in the North & East regions of Los Angeles & Ventura Counties. Twelve medical clinics, including two urgent care centers and dedicated women's centers, are located across the San Fernando, Santa Clarita and Simi Valleys. The group began as a single medical practice over 90 years ago.
Facey is part of Providence Health & Services, an integrated, not-for-profit 5-state network of hospitals, care centers, medical clinics, affiliated services and educational facilities spanning from California to Alaska.
We offer a full comprehensive range of benefits - see our website for details
As people of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.
Providence Health & Services is the third largest not-for-profit health system in the United States. Providence employs more than 82,000 caregivers (employees) across a five-state area; AK, WA, MT, OR, and CA. Our facilities include 34 hospitals, 600 physician clinics, senior services, supportive housing and other health and educational services. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Case Management
Location: California-Mission Hills
Req ID: 153547