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Company: Network Medical Management Inc
Location: Monterey Park
Posted on: November 17, 2021

Job Description:

SUMMARYTo implement the effectiveness and best practices of Case Management, the Case Manager will apply appropriate criteria for admission and continued stay in compliance with NCQA, CMS, and Health Plan delegation standards.ESSENTIAL DUTIES AND RESPONSIBILITIESComply with Case Management Department's policies and procedures.95 - 100% compliance with UM health plan delegation standards for Case ManagementDuties and Responsibilities for CM Department100% compliance in applying Milliman Care Guidelines criteria for admission and continued stay in acute care settingUtilize Milliman Care Guidelines criteria for appropriateness of transition to care by level of skilled needs and acute rehab for post discharge plansWorks closely with hospital case managers to establish discharge plans upon admissionResponsible for coordinating the required reviews and attend to the needs for Capitated HospitalsIdentify and evaluates members for enrollment into one of the case management program: Cal-MediConnect, Complex Case Management, SNP, Transplant, CCS, Member Education, ESRD...etc. and update progress to various health provider (including but not limited to health plan, physician, and member) to ensure COC.Assess, plan, implement, coordinate, monitor, and evaluate all options and services with the goal of reducing hospital readmissionPerform telephonic or on-site inpatient concurrent reviewsPerform timely clinical documentation pertaining to entire care of members from admit to TOCAccountable for daily accurate reporting of all in-patients to Medical Director and Director of Case ManagementTimely coordination of care with Hospitalist for discharge transition to care needsReview of medical records and/or other documentation to determine medical necessity, appropriateness and level of care utilizing Milliman Care and other appropriate GuidelinesAttends/coordinates Case Management meetings, on and off-site as necessaryRefer members to appropriate health plan, Community, State or Federal Disease/Condition Management programsOthers:Acts as clinical resource and liaison to staff, departments, and health plansAttend IPA and health plan meetings as requiredRespond to IPA, capitated hospital and health plan complaints in a timely mannerInteracts with the providers or members as appropriate to communicate determination outcomes in compliance with state, federal and accreditation requirementsAttend to provider and interdepartmental calls in accordance with exceptional customer serviceMaintain good relationships with health plans, hospitals and medical directors. Resolve problems that arise with any IPA medical directors.Report to Director of CM, Manager & Supervisor on activities and/or problems occurring throughout the dayPerforms other duties, projects and actions as assignedQUALIFICATIONS:Bachelors' degree in Nursing, LVN, or trained health care professional with a medical degree preferred.Active Registered Nurse License or LVN in California.A minimum of five year's health plan, IPA or MSO experience in management.Experience with clinical issues, clinical guidelines, case management, & managed care.Working knowledge of ICE, DHS, DMHC, NCQA, and CMS standards.Excellent analytical critical reasoning and interpersonal communication skill.Excellent presentation, verbal and written communication skills and ability to collaborate with co-workers, senior leadership and other management.Proven ability to prioritized and organize multi-faceted/multiple responsibilities simultaneously in a fast paced, changing environment while meeting deadlines and turnaround time requirements.Must be able to work independently utilizing all resources available while staying within the boundaries of duties.Must possess the ability to educate and train staff members and other departments as neededAbility to keep a high level of confidence and discretion when dealing with sensitive matters relating to providers, members, business plans, strategies and other sensitive information is required.Must be ethical and possess the ability to remain impartial and objective.Must be able to travel at least 15% of work time.Proficient with Microsoft applications', EZCAP, and crystal reports.Personal & Professional QualitiesPunctuality, Creativity, Self-motivationProfessional appearance and conduct.Conceptual and "big picture"-- - understandingAble to function independently under time constraintsWilling to learn and develop new responsibilities and skills.Good organization, critical thinking and problem solving skills.Must be detail-oriented and able to work autonomously but also as a team memberShould have strong communication and customer service skills and respect for confidentiality.#HPIND

Keywords: Network Medical Management Inc, Monterey Park , CASE MANAGER, Executive , Monterey Park, California

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