Job Title

Description: Under the direction of the Director of Utilization Management, UM Clinical Manager and the UM Outpatient Clinical Supervisor, the RN Clinical Intake Coordinator is responsible for supporting the clinical Utilization Management activities for members. Conducts medical necessity review of referral requests including but not limited to requests for DME, outpatient therapies, and prior authorizations for outpatient procedures and prospective inpatient stays. Utilizes Milliman Care Guidelines and Medi-cal criteria to facilitate decision making. Refers cases to the Medical Director when clinical information provided in the referral request does not support medical necessity. Functions as a key resource to the Non-Clinical Intake Coordinators for questions or clarifications on criteria, interpretation of benefits, or whenever they need additional clinical expertise and/or guidance What You Will Do: Performs review of requested outpatient and elective, prospective inpatient medical services. Under the direction of the UM Outpatient Clinical Supervisor coordinates and refers members for services which are carved out of the clients medical coverage. Assists in the authorization and processing of automatic referral requests. Responsible for written and verbal communication with contract providers and internal staff to promote timely coordination of care and dissemination of the clients policies and procedures. Collaborates with the Member Service Department and the Provider Relations Department regarding quality of care and other grievance issues to facilitate timely problem resolutions. Utilizes clinical guidelines as well as Medi-Cal criteria to review DME, home care, and outpatient service requests for medical necessity and benefit coverage while processing referral request. Identifies and refers cases for quality of care, coordination of benefits, and third-party liability issues as appropriate. Maintains knowledge of covered benefits for all programs. Identifies and refers cases appropriate for various internal programs. Shares information as necessary with appropriate Population Health Management team: Case Management, Transitions of Care, Major Organ Transplant and Community Support Services including but not limited to Enhanced Care Management. Identifies authorization issues and brings those requiring attention to the UM Outpatient Clinical Supervisor. Reviews requests for non-par services and coordinates these with input from the Medical Director based on par provider availability in the member s geographic area. Selects, formats, proofreads and prints appropriate member and provider denial letters prior to mailing. Determines medical appropriateness and necessity of care using established criteria within mandated turnaround times. Appropriately refers cases that do not meet medical necessity to the Medical Director. Keeps current with California Children s Services benefits and guidelines for coordination of services. Other duties as determined based on Department needs. You Will Be Successful If: Lead by example to support a positive work environment that values patient advocacy, respectful listening, diverse expression of opinion and constructive conflict resolution. Adheres to the clients Code of Ethics and Business Conduct and all company policies, e.g., confidentiality, attendance, safety/security, use of equipment and technology, appearance and demeanor. Represent the client in a positive manner to all members, caregivers, staff and external stakeholders. Demonstrate commitment to continuous improvement. Strong knowledge of acute chronic care nursing principles, methods and common treatments. Strong knowledge of common human diseases and usual and customary methods of treatments. Demonstrated knowledge of medical terminology. Ability to effectively evaluate medical records to determine appropriateness and necessity of care. Demonstrated knowledge of health care delivery systems. Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of work. Ability to use tact and diplomacy to diffuse emotional situations. Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards. Basic skills in Word and Excel with basic ability to enter data into and navigate through a database. Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business. Demonstrated ability to commit to and facilitate an atmosphere of collaboration and teamwork. Self-directed, with proven ability to work independently with minimum supervision. Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis. Strong attention to detail; work accurately and at a reasonable rate of speed. Compliant with the client s policies and procedures; performs the job safely and with respect to others, to property, and to individual safety. What You Will Bring: Registered Nurse (RN) with an active, current, unrestricted CA license. Minimum of two years (2) full-time clinical experience in acute care, community health setting, public health nursing or chronic disease management required. Bachelor s Degree from an accredited school or equivalent in Nursing, Health Administration or related healthcare field preferred. Understanding of utilization management principles preferred. Experience with MCG Health LLC clinical guidelines and Medi-CAL coverage preferred. Experience working in case management or care coordination is a plus. Knowledge of Kern County Community resources for seniors and people with disabilities is a plus. Valid California Driver License and proof of State required auto liability. Up to 10% Driving. Bilingual (English/Spanish) preferred. About Impresiv Health: Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges. Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it. That s Impresiv!