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Posted: Tuesday, December 26, 2017 12:02 PM

Job Description Description: 1. Performs concurrent or post-service review of acute in-patient care services, as required, by the use of established criteria with duties including but not limited to: Performs preauthorization, concurrent and post-service review for all acute, sub-acute , skilled nursing facilities utilizing the established criteria/protocols as approved by the plan; Maintains documentation of clinical reviews in Utilization Management software system according to Alliance policy and procedure; Interprets benefits based on the benefit language as outlined in Title 22, Provider Manual, and plan policies and procedures, to evaluate appropriate care for all lines of business; Reviews medical records to determine benefit coverage including appropriateness and level of care; Assists Member Services, Claims and Provider Services departments with issues that require medical interpretation or definition; Performs audits of medical records as needed; Works closely with attending and contracting physicians, ancillary providers, county services and institutional staff to facilitate discharge planning; Protects confidentiality of utilization review, quality management information and beneficiary identification; and Prepares reports on utilization information, including admissions, discharges, authorization denials, use of covered services and other pertinent performance data, as directed. 2. Participates in the Utilization Management Transitions of Care Program to achieve goals of improved member outcomes and reduced readmission rates with duties including but not limited to: Coordinates transition planning for members from acute hospitalization and/or skilled nursing facility placements for 30 days following discharge; Interprets benefits based on the benefit language as outlined in Title 22, Provider Manual, and plan policies and procedures, to evaluate appropriate care for all lines of business; Assists Member Services, Claims and Provider Services departments with issues that require medical interpretation or definition; Works closely with attending and contracting physicians, ancillary providers, county services and institutional staff to facilitate discharge planning; and Protects confidentiality of utilization review, quality management information and beneficiary identification. 3. Coordinates and facilitates a preauthorization review system for outpatient services to expedite hospital discharge with duties including but not limited to: Performs preauthorization review for outpatient services necessary to expedite hospital discharge based on criteria/protocols as established by the plan; Interprets benefits based on the benefit language as outlined in Title 22, Provider Manual, and plan policies and procedures, to evaluate appropriate care for all lines of business; Assists Member Services, Claims and Provider Services departments with issues that require medical interpretation or definition; and Protects confidentiality of utilization review, quality management information and beneficiary identification. Work Environment: This is an office setting where Case Managers will be sitting in front of a computer screen for at least 8 hours per day. They will be reviewing medical records with little to no patient interaction and helping manage the care for current benefits members. Qualifications: EDUCATION AND EXPERIENCE: Current RN License Minimum three (3) years of experience in a patient care setting (preferred); and Minimum one (1) year of experience in Utilization Management, case management or equivalent Performance Workload: Case Managers currently working on roughly 50 Cases per week.

Source: http://www.juju.com/jad/00000000gnt9wy?partnerid=af0e5911314cbc501beebaca7889739d&exported=True&hosted_timestamp=0042a345f27ac5dc02d96ccccc4c3c2d88e438ede98045f000fcf700ee48587d


• Location: Modesto

• Post ID: 25430397 modesto
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