Concurrent Review Case Managers Needed

Review and evaluate proposed services utilizing medical criteria and/or established policies and procedures. This includes review of submitted medical documentation and/or photographs. Determine the appropriate action with regard to the service being requested for approval, modification or denial, and refer to the Medical Director for review when necessary. Determine if the inpatient setting requested for surgery and/or medical care is appropriate. Initiate contacts with patient, family, and treating physicians as needed to obtain additional information or to introduce the role of case management. Analyze all requests with the objective of monitoring utilization of services, which includes medical appropriateness and identification of potentially high cost, complex cases for high-level case management intervention. For short-term cases, conduct a thorough and objective assessment of the member’s current status including physical, psychosocial, environmental, and gather all information pertinent to the case. Report cost analysis, quality of care and/or quality of life improvements as measured against the case management goals. Routinely assess member’s status and progress; if progress is static or regressive determine reason and proactively encourage appropriate referrals. Prepare and maintain appropriate documentation of patient care and progress within the care plan. Act as an advocate in the client’s best interest for necessary funding, treatment alternatives, timelines and coordination of care and frequent evaluations of progress and goals. Work collaboratively with staff members from various disciplines involved in patient care with an emphasis on interpreting and problem and solving complex cases. Document case notes and rationale for all decisions in the CCMS system. Other projects and duties as assigned. Current RN license to practice in the state of California is required. Bachelor’s degree preferred. 5 years minimum clinical experience with the health needs of the population served. Ability to work toward and/or maintain case management certification (CCM) ICD-9/ICD-10 and CPT coding requirements. If you feel that you have the skills we require, please respond to this posting with your contact information and your resume in a Word document. We look forward to hearing from you today! www.healthcaretalent.net https://www.facebook.com/HCTalent Case Managers are vital to the care of our clients – come join us and make a difference! Case Management is an advanced specialty collaborative practice, responsible for providing ongoing case management services for our members. This position provides case management intervention on behalf of members with short-term, stable and predictable course of illnesses. Also responsible for answering the medical appropriateness, quality, and cost effectiveness of proposed hospital/medical/surgical services in accordance with established criteria. This activity may be conducted prospectively, concurrently, or retrospectively.