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Case Manager RN

Dignity Health Management Services Bakersfield, California
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Requisition ID 2022-265362 Employment Type Full Time Department Care Coordination Hours/Pay Period 80 Shift Day Weekly Schedule Monday - Friday Remote Yes Category Case Management and Social Work
Overview

***This position is remote/work from home, however the final candidate will need a clear and current CA RN license.

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups hospitals health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options including medical dental and vision plans for the employee and their dependents Health Spending Account (HSA) Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.


Responsibilities

Position Summary:


This position will review medical records, benefit, contractual and other guidelines to determine benefit coverage, medical appropriateness including, access, scope availability, and level of care considerations. Position updates and processes member records. Position works closely with management to coordinate member care. Position conducts inpatient and skilled nursing facility level-of-care review on a concurrent basis. Develops support tools for communication of standards and expectations.
The Case Manager, RN conducts medical necessity, level of care, and benefit reviews rendered in the inpatient and outpatient setting to ensure the patient receives the highest level of care. Coordinates with providers, provider staff, hospital staff, patient and patient family members to establish the appropriate level of care.


Responsibilities may include:
- Plans for and ensures that all post discharge care is coordinated appropriately according to the needs of the patient and ensures continuity of care.
- Conducts prior authorization review on all services that require nurse review.
- Conducts inpatient and skilled nursing facility level-of-care review on a concurrent basis.
- Plans for and coordinates all discharges from inpatient and skilled nursing facilities.
- Makes outbound calls to patients according to case management queue assignment and case management policies and procedures.
- Tracks barriers to appropriate inpatient and SNF utilization according to policy and procedure.
- Attends Utilization Management (UM) and/or Quality Management (QM) meetings as needed.
- Perform other duties as assigned.


Qualifications

Minimum Qualifications:


- Five (5) or more years nursing experience working in a medical facility, hospital, or other healthcare related environment
- Clear and current CA Registered Nurse (RN) license.
- Basic knowledge of CPT and ICD9/ICD10 coding.
- Excellent communication skills; able to read, write, and speak articulately, using established channels of communication and reporting relationships within the organization. Ability to communicate effectively with all levels of internal/external staff, management, members, physicians/physician office staff, families of members, outside agencies, etc.
- Familiar with regulatory requirements for managed care, HMO's and EPO's. Ability to apply criteria to identify appropriate level of care on all admissions and clearly document any research conducted and rationale of decisions made. Ability to identify care needs across the age continuum and according to principles of growth and development over the life span. Ability to apply appropriate business rules, medical guidelines and/or health plan benefits to authorization decision making.
- Knowledge of nursing processes, case management and continuity of care. Proficiency with health plan criteria/benefits and regulatory requirements as they relate to patient management across the continuum of care. Proficient with standardized criteria, Interqual, MCG, Medicare, etc. Knowledge of network and benefit limitations and ability to collaborate with stakeholders to find alternatives that meet patient needs and achieve positive outcomes. Knowledge of disease management strategies

Preferred Qualifications:


- Two (2) or more years experience in case management or IPA preferred.
- Managed care experience preferred.
- Experience with QNXT preferred.
- Certified Case Manager (CCM).
- Familiarity with an electronic practice management system is preferred.

A compensation range of $80,000 to $120,000 is the reasonable estimate that CommonSpirit in good faith believes it might pay for this particular job based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.
While you’re busy impacting the healthcare industry, we’ll take care of you with benefits that include health/dental/vision, FSA, matching retirement plans, paid vacation, adoption assistance, annual bonus eligibility and more!

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Equal Opportunity

CommonSpirit Health™ is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here.

CommonSpirit Health™ will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c). External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances. If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA). CommonSpirit Health™ participates in E-Verify.