SUPV - Case Management - Full Time

Come and join the RMC Family! 

We have been in the community since 1935.  Our mission is to provide comprehensive multi-specialty medical services in the greater Riverside region.  Your passion, inspiration, and talents are invaluable to us and our mission to serve others.  Our facility can provide a place for you to thrive and continue your professional development.  Quality Healthcare is our passion, improving lives is our reward.  We are working to change lives and transform the delivery of healthcare. Riverside Medical Clinic is the best place to work, practice medicine, and receive care.

SUMMARY: Assists and supports the Director/Manager of Medical Management. Provides and ensures staff is screening the accuracy of eligibility, benefits, clinical guidelines (as applicable and appropriate) based on department policies and procedures and health plan compliance. Ensures that referrals are adjudicated according to the referral process as per health plan and regulatory standards. Assists in preparing required documentation and reports for Health Plan audits and appeals. Assists Director/Manager with onboarding and ongoing staff training on Benefits/Eligibility/Coverage Maintenance Responsibilities according to UM processes and policies and procedures. Provides other staff training, in-services, and disciplinary action as needed and as directed by Director/Manager of Medical Management. Performs regular internal audits of staff processes according to policies and procedures of the department to ensure compliance with payors delegation agreements.

QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Hours: 8:30am-5:30pm

EDUCATION and/or EXPERIENCE: High school diploma or general education degree (GED) required. Requires an associate degree in nursing RN, or LVN. Three (3) years utilization and case management experience working in a managed care setting working with insurance payors, or a combination of some college plus five (5) or more years HMO and insurance experience required in the area of utilization and case management. Two (2) years supervisory experience required. Must possess good written and verbal communication skills, ability to work in a fast-paced busy environment, meet stringent deadlines, and multi-task, have excellent computer skills with Excel and Word. Medical terminology needed, and have a good understanding of EMTALA, NCQA, DMHC, CMS regulatory requirements with Medicare Advantage.

CERTIFICATES, LICENSES, AND REGISTRATIONS: Current, active, non-restricted California Registered Nursing License or LVN license.

ESSENTIAL FUNCTIONS:
Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job’s purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions for which the person in the job is held accountable. Note: (other duties may be assigned, deleted or changed at any time, at the discretion of management, formally, or informally, either verbally or in writing).

1. Responsible for the collection of accurate data from utilization of services within the Utilization management Department. Prepare useful utilization statistics from this data.

2. Communicates with other departments, health plans, providers, and members to resolve benefit and eligibility issues. Resolve escalated issues from external and internal customers.

3. Establishes work procedures and evaluates processes for improvement. Monitor staff productivity and turnaround time on a daily, weekly, and monthly basis to ensure accuracy, productivity and attaining department goals.

4. Prepare and authorize work schedules for UM Coordinators and Nurses, maintain attendance records and update payroll systems.
5. Develop and implement monthly utilization statistics, as necessary, for use in Utilization Management Department and Utilization Management Committee.
6. Verify patient benefits and eligibility prior to authorizing services or supplies as needed.
7. Communicate system malfunctions to appropriate department and required benefit file updates, as necessary, to ensure system accuracy.
8. Update authorizations in the system to ensure timely turnaround and compliance with health plan requirements.
9. Responsible for interviewing, hiring, training, coaching, counseling and termination of employees.

10. Provide day-to-day supervision of assigned UM staff and participate in staff training.

11. Monitor UM staff for consistent application of UM criteria applicable to level and type of UM decisions made to include but not limited to adherence to all UM policies and procedures.

12. Monitor documentation for adequacy of information required to effectuate/adjudicate a referral.

13. Monitor staff adherence to all UM policies and procedures and compliance with regulatory requirements by health plan payors to meet the Company’s contractual delegation obligations.

14. Availability to UM staff on site or by telephone on a day-to-day basis during regular working hours, on the weekends for weekend on-call staff, and or as needed by the department.

15. Provide supervisory oversight to the UM department and assist the Director/Manager in all areas of the UM department as directed by the Director/Manager.
16. Conduct introductory assessment and annual performance evaluations as required and provides input and recommendations/goals.
17. Ensure all documentation pertaining to employee issues, training records, and any related company policies and procedures are compliant with health plans delegation requirements, governmental and company protocols.
18. Assists Director/Manager in conducting monthly staff meetings and or ad hoc meetings.

19. Assist Director/Manager of Medical Management in determining staffing needs.

This opportunity offers the following:

Challenging and rewarding work environment
Growth and Development Opportunities within UHS and its Subsidiaries
Competitive Compensation
 

About Universal Health Services

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

Avoid and Report Recruitment Scams

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.