Utilization Management Nurse RN Facility Assigned

KHS reasonably expects to pay starting compensation for the position of Utilization Management Nurse RN Facility Assigned in the range of $45.02 – 57.41 Hourly.

*On-Site Facility Assigned*

***5,000 Sign-On Bonus***

About us

Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.

About the role

Under direction of the Kern Health Systems (KHS) Medical Director and Director of Utilization Management, the Facility Assigned UM RN, coordinates the care of KHS members from pre-admission through the post discharge period ensuring well-coordinated, safe, clinically appropriate, transitions of care. The Facility Assigned UM RN, is responsible for evaluating the clinical status of patients using evidence-assigned criteria to determine medical necessity for hospitalization, communicating anticipated length of stay to the treating provider assigned on the guidelines, assessing clinical progression, and proactively anticipating discharge needs. The Facility Assigned UM RN conducts an in-depth assessment which includes, psychosocial, physical, medical, environmental, and financial parameters. Interprets the clinical and social needs of the member to develop a patient centric, appropriate discharge plan in collaboration with the treating physician and hospital-assigned care coordination staff. The KHS Facility Assigned UM RN is responsible for identifying and authorizing services, facilitating LOAs as warranted with non-network providers and communicating the transition plan to the hospital case management team so the discharge may be facilitated.  Incumbents are expected to possess an advanced knowledge of health care delivery systems and follow all applicable regulatory requirements.

Essential Duties and Responsibilities

 

• Meet with the member with 24 hours of admission to assess:
  • Social Situation including Residential status, Support system, Barriers to compliance
  • Baseline level of function: Physical limitations, baseline DME requirements- status of supportive devices.
  • Identification of a preliminary discharge plan A and backup plan B.
• Review the initial and concurrent daily documentation in the EHR pertaining to the member’s clinical condition to identify the need(s) that require continued hospitalization.
• Active participation in any IDT rounds that address the members plan of care. Share the GLOS and notify when the GLOS is exceeded.  Share the preferred DCP and share alternatives if the preferred plan is not feasible.
• Complete same day initial and subsequent daily UM reviews using Medi-Cal guidelines/MCG criteria and document daily in the Plan’s electronic documentation platform.
• Collaborate with the facility-assigned case management staff to ensure member receives well-coordinated discharge planning efforts. Including but is not limited to:
  • Securing a vendor and authorization of ancillary care (home health, infusion services, therapy services, etc.) required to support the member in the post-acute period.
  • Authorization of specialist follow-up services requested at discharge.
  • Secure and authorize placement at next level of care as required to ensure timely disposition.
  • Authorize appropriate transportation as needed to ensure timely disposition.
  • Refer member to appropriate follow up care: PHM programs, CSS, ECM, TCM, etc. and provide warm handoff to PHM case manager.
  • Document all activities in JIVA.
• Active referral and collaboration the Plan Medical Director as needed.
• Provide written and verbal communication with contract providers and internal KHS staff to promote timely coordination of care and dissemination of KHS policies and procedures.
• Collaboration with various KHS departments to address any quality of care, grievance or other concerns to facilitate timely resolution on behalf of the member.
• Participate in Utilization Management and Quality Improvement data and statistical gathering, collation, and reporting.
• Perform other duties as assigned.
  
  

  CORE COMPENTENCIES / KNOWLEDGE & SKILL REQUIREMENTS:

 

• Demonstrated knowledge of and skills in protocols for utilization management, discharge planning and/or case management.
• Strong knowledge of acute care nursing principles, methods and commonly used procedures.
• Strong knowledge of common patient disease processes and usual methods for treating them.
• Thorough knowledge of medical terminology, hospital routine and commonly used equipment.
• Knowledge of acute hospital organization and interrelationships of various clinical and diagnostic services.

• Proven ability to effectively evaluate medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans

• Proven ability to assess and judge the clinical performance of physicians and other health professionals.
• Familiarity with ICD10 and/or CPT coding.
• Demonstrated thorough knowledge of health care delivery systems and HMO regulatory requirements, including DMHC and CMS compliance.
• Ability to read, interpret and apply written regulations, guidelines and other materials.
• Strong analytical, assessment and problem-solving skills with intermediate negotiation skills.
• Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of KHS.
• Ability to use tact and diplomacy to diffuse emotional situations.
• Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards.
• Intermediate skills in Word and Excel with basic ability to enter data into and navigate through a database.
• Demonstrated ability to commit to and facilitate an atmosphere of collaboration and teamwork.
• Possess knowledge of payer source documentation requirements and governmental regulations affecting reimbursement.
• Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business.
• Self-directed, with proven ability to work independently with minimum supervision.
• Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis.
• Strong attention to detail; work accurately and at a reasonable rate of speed.
• Compliant with KHS policies and procedures; performs the job safely and with respect to others, to property, and to individual safety.
  
  

Employment Standards

Education and experience:

• Minimum of three (3) years clinical nursing in an acute care hospital setting.
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• Prior experience in case management, care coordination or related field in either a clinical or insurance setting is preferred.
  
  
OTHER REQUIREMENTS:

 


• Current, unrestricted, California Registered Nurse (RN) Licensure
• Applicant must complete and remain complaint with all facility mandated education and health requirements. 
• Valid California Driver License and proof of State required auto liability insurance; Up to 10% driving required
• Bachelor’s Degree from an accredited school or equivalent in Nursing, Health Administration, or related healthcare field preferred.
  
  
Bilingual (English/Spanish) preferred.

Certifications:


• Current BLS certification