Job Description

Location: Sonoma & Napa Counties

Employment Status: Full Time

Position Summary

The outpatient RN Care Manager is the key contact with the patient and providers. They are responsible for providing comprehensive assessments and developing, coordinating, and implementing the plan of care with other team members on those patients that s/he is assigned. Maintain extensive knowledge regarding the current standards of care and care management processes for Asthma, COPD, Diabetes, Heart Failure, and/or other Program specified condition(s). Involved in two main programs at Meritage: Care Transitions and Complex Care Management.

Principal Responsibilities:

Care Transitions Program:

• Provide post hospital discharge support to all Meritage members who qualify for Care Transitions (depending on health plan)- based on Coleman Model (30 day program)
• Patients will receive either telephonic or face-to-face care transitions support
• Use Criteria such as the LACE tool to identify high risk patients
• Goals and objectives:
  • Reduce preventable readmissions
  • Increase the number of patients that are seen by an MD within 7-10 days of discharge
  • Provide medication reconciliation and assist in identifying and correcting medication discrepancies
  • Provide teaching regarding disease process, medications, community resources
  • Educate members on seeking the appropriate level of care
  • Reduce utilization costs by evaluating users with high outpatient costs
  • Refer patients as appropriate to Behavioral Health Care Manager
  • Create personalized care plan for patient

Complex Care Management:

• CCM services to those patients identified as high risk and will be referred into the program.
• Patients referred into the program will receive telephonic support for up to 90 days, as well as a home visit from the RN Care Manager (RN CM).
• Identify patient centered goals and create personalized Plan of Care
• Work with patient to achieve goals of care
• Educate patient regarding disease processes, medications, community resources
• Provide medication reconciliation as appropriate
• Assist members with seeking appropriate level of care
• Provide referral to Behavioral Health Care Management if appropriate
• Work with Utilization Review for authorizations/provider referrals as appropriate
• Work with quality department to assure preventative health screenings are up to date.
• Patients who receive a home visit will also receive three follow up phone calls to address any ongoing needs, questions or concerns.
• RN CM may provide the following via telephone or home visit (if deemed clinically appropriate):
  • Assessment of patient health status
  • Identify patient centered goals and create plan of care
  • Educate patient regarding disease processes; signs and symptoms; when to notify MD
  • Interdisciplinary collaboration with MDs, therapists, home health agencies, family, etc.
  • Discussion of preventative health measures
  • Medication reconciliation/discrepancies
  • Teaching of disease process, signs and symptoms to be concerned about and when to call the doctor
  • How to seek the appropriate level of care
  • Referral to community resources/caregivers etc. as appropriate
  • Home safety evaluation/falls risk assessment
  • Review of life planning/advanced care directions
  • Review of hospital discharge instructions if indicated
  • Work with UM for proper authorizations/providers if indicated
  • Provide ongoing support for patient to achieve goals
• CCM patients are brought into weekly rounds with medical director

SNF 3 day Waiver Program:

• Participate in the 3 day waiver program
  • Point person for hospitals, Skilled Nursing Facilities, primary care provider
  • Care transitions/CCM for fee for service Medicare/ Medicare advantage beneficiaries who qualify for the 3 day SNF waiver (see above for duties for each service)

Go to application

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Job Requirements

Qualifications

• RN with current, unrestricted license in the state of California, MSN preferred or CM certification.
• 2+ experience in inpatient or outpatient services including patient management and follow up
• Able to work with different healthcare settings: Inpatient vs. Outpatient

Skills and Requirements:

• Knowledge of CM regulations that fall under CMS, NCQA, DMHC and other applicable state and accreditation standards.
• Demonstration of sound clinical judgment and critical thinking in accordance with the California Nurse Practice Act
• Commitment to service excellence and patient satisfaction.
• Ability to develop and maintain effective working relationships with other teammates, patients and the general public.
• Ability to multi-task in a fast-paced clinical setting.
• Excellent verbal, written and interpersonal communication skills.
• Aptitude for coaching, training and developing new teammates.
• Ability to collaborate and build strong client relationships across all levels of the organization including clinical staff, physicians and administrative leadership to meet deliverables.
• Proficiency in using office based software applications, including Word, Excel, Outlook, and PowerPoint.
• Able to drive in own car to patient homes/ facilities
• Valid driver license and insurance required

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Job Description

Location: Novato

Employment Status: Full-Time

The LVN Senior Utilization Management Coordinator serves as a liaison between Meritage Medical Network, our contracted health plans, Network physicians and Members. The incumbent will serve as a resource to other UM team members and is responsible for processing authorizations within the scope of their assignment. This position reports directly to the UM Manager.

Principle Duties and Responsibilities:

• Utilize knowledge and experience to analyze contractual or administrative issues related to the requests.
• Identify additional information needed and ability to research and understand Policy benefits and criteria
• Accurately identify when and how to refer cases to appropriate clinical personnel or take other actions as necessary or required.
• Follow strict guidelines to ensure all work meets ICE standards for accuracy, timeliness, quality and compliance with federal, state and accreditation regulations.
• Coordinate with other insurance coordinators and the medical review staff.
• Consistently meet department productivity and performance metrics.
• Contribute to the efficiency of the department by being flexible and cross-trained on other functions.

Go to application

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Job Requirements

Minimum Qualifications:

• Two years of current related Utilization Management experience required; Managed Care or health plan experience strongly preferred
• Current and unrestricted CA LVN license; Medical Assistant certificate and additional relevant work experience will be considered in lieu of LVN licensure.
• Must have the ability to understand and use set criteria and approve specific services within the related UM system.
• Familiarity with insurance billing and medical terminology
• Knowledge of CPT/ICD-10 codes.
• Excellent interpersonal skills, including phone, verbal, and written communication.
• Ability to cope in a fast-paced production environment
• Demonstrated knowledge of customer service skills when responding to questions and other inquiries from internal and external customers.
• Strong computer skills with demonstrated proficiency in word processing, spreadsheet, database, presentation and email applications.
• Must be organized and detail-oriented

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