Utilization Management nurse

Job Details: Job Location: Humboldt Del Norte Independent Practice Association - Eureka, CA, Position Type: Full-Time/Part-Time, Education Level: 2 Year Degree, Salary Range: $45.00 - $63.17Hourly, Job Shift: Day, Job Category: Health Care, The Medical/Utilization Management nurse plays an important role in improving patient health and satisfaction and ensuring members receive the appropriate medical care. This is a part time position working 10-20 hours per week. RN Responsibilities include: Utilization Management (UM)– provides nursing-level decision-making utilizing evidence based clinical guidelines. UM nurse is an integral role of the Medical Management Team (UM Medical Director, UM Department Manager, and Customer Service). UM nurse coordinates IPA member care utilizing knowledgeable, clear, timely, effective and compassionate  communication. UM RN is a multi-faceted position that includes the following responsibilities: Review IPA member authorizations for clinical appropriateness and medical necessity by conducting   a thorough review of the supporting medical documentation and utilizing appropriate evidence-based guidelines to support decision-making.  Case Management (CM) and Care Coordination (CC)  Work closely with Priority Care Center Team (Humboldt IPA’s Clinic) to identify members that would benefit from Intensive Care Coordination. Participate in weekly multidisciplinary Care Coordination meetings to discuss strategies, create multidisciplinary Care Plans aimed at optimizing member health, patient care and appropriate healthcare delivery. Assist in identifying members that would benefit from Case Management/ Care Coordination. Advise members of IPA and PCC services e.g.,:  access to Primary Care at the  Priority Care Center that includes same day service appts, Behavioral Health Provider, Shared Decision Making, Intensive Care Coordination and Wellness Coaching. Follow hospitalized IPA members, communicate with hospital staff regarding discharge planning, identify care coordination needs and facilitate timely follow-up care. Employee Assistance Program (EAP) – Responsible for accepting calls from EAP members and coordinating Behavioral Health and Legal Assistance referrals for our local community. Actively engage in monthly Quality Medical Management meetings aimed at discussing complicated cases that are brought to a local committee of MDs for review.  Actively engage in monthly Medical Management Committee meetings to identify and discuss patients in need of or receiving Care Coordination, hospitalized members, and other pertinent agenda items  Provide feedback and insight regarding improving current processes and policies.  Participate in Health Plan Audits.  Participate in quality improvement projects. Other duties as assigned. Qualifications: Qualifications: Nursing experience in Case Management and patient care preferred  Computer proficiency, ability to navigate through multiple programs, EMRs and web based meetings Current Registered Nursing LicenseCharacteristics: Responsible, organized and detail oriented Excellent time management skills and ability to shift priorities Ability to document clearly and succinctly Demonstrates understanding of health care administration and related regulations Excellent communication skills Ability to coordinate and collaborate with patients, providers, and IPA staff Utilizes  proactive and problem-solving approach Adapts well to change, both within the IPA, and within the broader health care environment. Maintains a positive attitude and professional demeanor Self-motivated and follows through on assignments Ability to work autonomously Mindful of coworkers and patients  Caring, curious and kind demeanor