Inpatient or Outpatient Case Manager - RN / Immediate Needs

We are currently recruiting for two excellent opportunities with one of our premiere clients.

 

Our client, a leader in healthcare, has an immediate need for an Inpatient Case Manager and an Outpatient Case Manager.

 

The Case Manager will review contracted Medical Group’s referral requests for medical necessity, determines which requests need Medical Director review, and obtains sufficient medical documentation for an informed decision.

 

Primary focus of position will be to ensure members receive medically appropriate services at the most cost-effective level of care.

 

Duties/Responsibilities:Reviews contracted Medical Group’s referral requests for medical necessity with consideration given to the appropriateness of the setting, place of service, health plan’s benefits and criteria of the requested services and utilizes service matrix for contracted providers.  Documents process in authorization notes.Refers all medical necessity denials to the physician for review.  Processes denials within establishes timeframes.  Documents in the authorization system the denial reason, utilizing the industry standard denial letter language, outlines alternative services available.Reviews requests within established timeframes for urgent, routine and retro requests to maintain compliance with legislative and accreditation standards.Obtains additional information for Medical Director’s review of appeals.  Coordinates with health plan to meet timeframes for expedited appeals.Contacts out of network or tertiary facilities for clinical information  on patients authorized for services at the facility.  Coordinates discharge needs for these members with hospital case manager.Notifies health plan representative of potential transplants, out of area second opinions, experimental or investigational requests.

 

The successful candidate will possess:Prior experience in utilization management in a managed care environment.  Proficient with computer, Microsoft windows environment.  Licensure/Certification: Registered Nurse, active California License.

 

Qualified, interested applicants should forward resumes for immediate consideration to:

cjennings@medresourcesstaffing.com