Responsible for implementing the utilization management process for patients admitted to the acute level of care and coordinating clinical case management and discharge planning for the Emergency Department patients based on acute care guidelines/standards with focus on appropriateness of admission, level of care, and discharge. Provides telephonic or fax reviews to multiple health plans/medical groups. Collaborates with the health care team in the development, implementation, and documentation of an appropriate safe care plan. Provides retro-review of identified cases denied by health plans for financial reimbursement. Participates in appeals process to recover fluids 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 utilization monitoring activities. Coordinates appropriate, safe discharge plan with patients/families and in consultation/collaboration with health plan providers and internal as well as community resources. Obtains authorizations needed to implement appropriate care plan and assure financial reimbursement for care services. Understands effect of health care management and reimbursement on both patients and health care system. Accurately documents the care plan in the patient chart and communicates plan to patients/families. Maintains ongoing education/knowledge of case management and utilization concepts, State and Federal health care programs, changes in health care law, criteria for multiple levels of care; utilization process related to criteria for acute care admission and impact on health care system; and never ending changes in delivery of health care. Applies Case Management principles and strategies in the planning process. Receives ongoing education related to managed care organizations, preferred provider health plans, workers compensation plans, private health plans and third party payers. Functions as a key resource provider related to health care management, delivery of care, and effects or reimbursements on both patients and health care system. Performs other assigned duties. 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