Responsible for implementing the utilization management process for patients admitted to acute level of care. Conducts daily concurrent clinical reviews for utilization/quality management activities, based on acute care guidelines/standards with focus on appropriateness of admission, monitoring length of stay, and discharge delays. Provides telephonic or fax reviews to multiple health plans/medical groups. Communicates the plan of care to various Case Managers with focus on information received related to patient progress, cultural diversities, patient's age, socioeconomic status, lifestyle, and advanced directives. Collaborates with the care team during Interdisciplinary Patient Rounds providing direction to the physician, nursing, and other members of the health care team in the development, implementation, and documentation of an appropriate, safe continue care plan. Provides retro review of identified cases denied by health plans for financial reimbursement. Participates in appeals process to recover funds for services rendered by Palomar Health and ensures that patients/families understand their rights to appeal when they disagree with a medical determination. Analyzes and identifies utilization patterns and trends and participates in the collection and analysis of data for the denial process as well as special studies, projects, audits, or routine utilization monitoring activities. Receives ongoing education related to State and Federal health care programs, managed care organizations, preferred provider health plans, worker compensation plans, private health plans, third party payers, and criteria for continued care at multiple levels. Functions as key resource provider related to health care management, delivery of care, and effects of reimbursement on both patients and health care system. Understands and adheres to the California Nurse Practice Act, The American Nurses Association (ANA) Code of Ethics for Nurses, the ANA Bill of Rights for Registered Nurses and the ANA Scope and Standards of Practice for Nursing. Speak and read English at a level that is sufficient to satisfactorily perform the essential functions of the position. Knowledge of standard office equipment (i.e., calculator, fax, photocopier) and personal computer and computer software skills (i.e., MS Windows, Excel, Access, Word, Powerpoint, internet, e-mail). Windows computer skills including proficient use of keyboarding, use of mouse or keys for functions such as selecting items, use of drop down menus, scroll bars, opening folders, copying and similar operations required upon employment or within the 1st two weeks of employment to perform the essential functions of the job. Performs other duties as assigned. Follows Palomar Health rules, policies, procedures, applicable laws and standards. Carries out the mission, vision, and quality commitment of Palomar Health.

Job Requirements