[Hiring] Care Manager II, Utilization Management Acute @Sutter Health

Role Description

This position facilitates utilization management (UM) processes to support that the right care is provided at the right place and at the right time. To accomplish these goals, he/she applies established criteria to evaluate the appropriateness of admission, level of care, continued hospitalization and readiness for care transition. Responsibilities include:

• Assuring timely movement of patients throughout the continuum of care by conducting concurrent review and proactively resolving care, service, or transition of care delays/issues as necessary.
• Providing third-party payers clinical information to assure reimbursement.
• Coordinating care with the treatment team, patient, family, and others as necessary.

Qualifications

• Graduate of an accredited school of nursing.
• RN-Registered Nurse of California Upon Hire.
• 2 years recent relevant experience preferred.

Requirements

• Demonstrates basic knowledge of the role of UM, Care Transition and/or CM for patients within an acute hospital and/or ED setting and across the continuum of care.
• Awareness of healthcare reimbursement systems: HMO, PPO, PPS, CMS, all value-based reimbursement models, and alternative payment systems preferred.
• Working knowledge of laws, regulations and professional standards affecting case management practice in an integrated delivery system.
• A broad knowledge base of post-acute levels of care and associated regulatory compliance requirements.
• Must be able to effectively communicate with, and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners.
• Demonstrates ability to efficiently and independently manage own time and tasks with minimal supervision.
• General understanding of coding and DRG assignment process preferred.
• Excellent verbal and written communication skills required.
• Must be able to communicate effectively with a wide variety of personalities and departments, including members of the medical staff.
• Ability to read, write, hear, and communicate verbally in English to the degree required to perform the job.
• Willingness to act and dress in a professional manner at all times.
• Proficient in using a computer to accurately enter and extract data, send and receive email, calendar appointments, and use task lists associated with a variety of computer software programs.
• Proficient in the use and application of evidence-based level of care and medical necessity criteria such as InterQual and/or MCG.
• Must be able to meet accuracy and productivity requirements by the organization standards.
• Maintain proficiency in conducting utilization reviews using MCG/InterQual by keeping up with practices and technology, participating in all training and education requirements, and certification or accreditation as applicable.
• Ability to use Microsoft Office Suite products (Outlook, Word, Excel, Power Point) preferred.

Benefits

• Comprehensive benefits package.