Utilization Case Manager


Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year. 

We know that by serving our employees well, they, in turn, will better serve our nearly 300,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

We are currently recruiting for:

Utilization Case Manager

POSITION SUMMARY

Responsible for health care management and coordination of Community Health Group members in order to achieve optimal clinical, financial and quality of life outcomes. Ensures access to health care in accordance to company policies.  Works with members & facility case managers to create and implement an integrated collaborative plan of care. Coordinates and monitors Community Health Group member’s progress and services to ensure consistent cost effective care that complies with Community Health Group policy and all state and federal regulations and guidelines.

 

COMPLIANCE WITH REGULATIONS:

Works closely with all necessary departments to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures, applicable state and federal regulations, contractual requirements and accreditation standards.

 

RESPONSIBILITIES

  • Monitors in-patient care and facilitates appropriate transition to out-patient or lower levels of care by referencing CHG-approved clinical criteria for utilization management decisions; reviewing member’s medical record; communicating with member, attending physician, hospital case managers and discharge planners, member’s primary care physician and other health care professionals to address member-specific needs; discussing cases with CHG’s Chief Medical Officer and Case Managers regarding appropriateness of care and alternatives; arranging home health, referral to community-based resources, and other services to meet the member’s post-discharge needs.

  • Reviews inpatient census on a daily basis and prioritizes cases based on department policies, protocols, and guidelines.

  • Conducts concurrent review predominately on-site and retrospective review by reviewing facility medical records.

  • Reviews all cases that do not meet clinical criteria for utilization management decisions with the Chief Medical Officer for determination.

  • Utilizes pharmacy, Emergency Room (ER) encounter history, and admission history summaries to assist providers in developing a comprehensive discharge plan which includes member’s total potential discharge needs.

  • Coordinates member’s continued care needs upon discharge from inpatient setting with appropriate CHG Case Manager. 

  • Participates in Quality Improvement Activities (QIA) activities. Forwards quality of care concerns to the QI Department and provides case-specific follow-up for pre-determined cases.

  • Under the direction of department manager, researches and assists in the implementation of processes surrounding workflow and internal guideline development designed to enhance member outcomes and increase customer satisfaction.

  • Attends department meetings; provides feedback for existing processes; maintains patient confidentiality; represents department in interdepartmental and external meetings and forums on request.

  • Functions as a resource to internal and external customers by developing relationships with staff at assigned hospitals, clinics, and providers in order to facilitate and improve coordination of care.  Provides education to members and providers on available resources.  Offers assistance to peers when needed.

     

    Education:                 

  • Graduate from an accredited school of nursing.

  • Unencumbered Registered Nurse (RN) license in CA; current driver’s license and proof of auto insurance.

  • BSN degree in nursing and certification in utilization review and/or case management preferred.

  • Foreign medical graduates, health education or other mental/social health discipline (a combination of experience and education will be considered in lieu of degree in nursing).

     

    Experience/Skills:    

  • 3 year’s experience working in an acute care facility (ICU, emergency department, and/or medical/surgical unit) and 1 year experience in a managed care environment or hospital discharge planning or high risk management or outpatient clinic.

  • Inpatient discharge planning and high risk management experience or outpatient referral management preferred.

  • Working knowledge of Microsoft Word programs.

  • Knowledge of managed care principles, CPT, ICD-9 & 10, HCPCS coding, experience with inpatient and outpatient medical review guidelines (Milliman USA,Interqual).Familiar with Medi-Cal, Medicare. Familiar with Web based standard of care sites i.e. NIH, ACOG.

  • Ability to communicate effectively verbally and in writing; exceptional telephone and customer service skills; ability to establish effective working relationships with physicians and medical professionals; ability to organize work effectively, determine priorities, and work well independently.