Quality Care Starts At Clinicas!
This is an excellent opportunity to work for an organization that truly makes a difference in the community. Clinicas Del Camino Real, Inc. offers a highly competitive salary; excellent benefit package including full medical, dental, vision, life and disability insurance; generous holiday, vacation and sick leave.
Essential Duties and Responsibilities
CM Nurse’s responsibilities include, but are not limited to:
- Conduct clinical review for inpatient, out-patient and ancillary services requests for medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans.
- Review, triage, and prioritize authorization requests to meet required turn-around times.
- Expedite access to appropriate care for members with urgent or immediate needs using the expedited review process.
- Perform research and analyze complex issues, assesses member needs.
- Acquire appropriate clinical records, clinical guidelines, policies, EOC and Benefit Policy.
- Accurately applies coding guidelines.
- Identify appropriate health care resources based on member's medical needs, including but not limited to evaluating contracts and negotiating with facilities/vendors.
- Using professional judgment, independent analysis and critical-thinking skills, applies clinical guidelines, policies, benefit plans, etc. to case review.
- UM/CM case summarization including analysis of medical records and appropriate application of all applicable policies, guidelines and benefit plans.
- Makes first level approval determinations when request meets appropriateness, medical necessity and benefit criteria.
- Develop determination recommendations and present cases to Medical Director (or designee) for potential denial determinations or when Medical Director input is needed.
- Interact with the providers or members as appropriate to communicate determination outcomes in compliance with state, federal and accreditation requirements.
- Develop and/or review appropriate documentation and correspondence reflecting determination. Ensures documentation is accurate, complete and conforms to established regulatory standards.
- Document all activities as per unit practice including entry into automated systems. Recognizes potential quality care concerns and refers as appropriate.
- Make appropriate referrals to California Children’s Services (CCS) and Tri Counties Regional Center (TCRC).
- Identify and refer members who may benefit from disease management or case management and make appropriate referrals.
- Identifies potential TPL/COB cases, investigates TPL/COB issues, and notifies the appropriate internal departments.
- Manages out of area cases/requests based on current policy and refers them to the primary insurer as appropriate.
- Conducts rate negotiation, when necessary and as per policy, with non-network providers, utilizing appropriate reimbursement methodologies.
- Documents rate negotiation accurately for proper claims adjudication.
- Coordinate UM/CM review activities with contracted and/or delegated entities, as needed.
- Attend meetings as assigned.
- Meet with staff at various health centers as assigned.
- Perform additional duties as assigned.
- Potential remote opportunity.
Education:
- Graduate of an accredited nursing program required (e.g. ASN, ADN, BSN,MSN).
- Bachelor's degree preferred.
Certification/License:
- Active, valid, & unrestricted State of California Registered Nurse license is required.
- UM/CM certification preferred.
- Clean California Driver’s License and automobile insurance is required.
