LanceSoft is seeking a travel nurse RN Case Management for a travel nursing job in Sacramento, California.
Day 5x8-Hour (08:00 - 04:30)
Description:
Required:
BLS
-CA RN License
-prior UM experience for insurance companies!!
-EPIC & InterQual exp
Covid
Driver License
Conducts preauthorization, concurrent, and retrospective utilization management review using the department’s accepted criteria for ambulatory, acute, and post-acute patients to confirm medical necessity is met and at the appropriate level of care. Coordinates the utilization management, resource management, discharge planning, post-acute care referrals and care facilitation. Strives to promote patient wellness, improved care outcomes, and efficient utilization of health services among a patient population with complex health needs. General Referral Management:• Provides inpatient and ambulatory referral review - manages prior authorizations and retrospective referrals as documented in Utilization Management (UM) Operations Policies and Procedures.• Process referrals based on application of criteria (such as Medicare, MCG, InterQual, health plan, Sutter Health, etc.). Collaborate with UM Medical Directors routinely regarding referrals and all cases not meeting criteria.• Ensure appropriate authorization and denial letters are issued. Work collaboratively with UM staff to handle daily work.• Document all referral activities thoroughly in computer system documentation area (i.e. EPIC, Midas). Facility-based UM:• Conducts preauthorization, concurrent, and retrospective review using accepted criteria (i.e. Medicare, MCG, InterQual, etc.) for acute hospitalized and post-acute patients to ensure medical necessity for inpatient days and appropriateness of level of care. During acute hospitalization and post acute facility stays, consults with facility care team to develop goals to enhance functional status, identify discharge planning needs and provide continuity of care using community resources.• For cases not meeting criteria, the case manager documents applicable guideline, rationale, and routes to the UM Medical Director for further review.• Issues & documents facility or regulatory letters as applicable (i.e. Authorizations, Notice of Medicare Non-Coverage, Detailed Explanation of Non-Coverage, Refusal to Transfer, Notice of Non-Coverage Termination of Services letters, etc.).• Works collaboratively with members of a patient’s care team (i.e. physician, nurses, rehab team, social worker, facility case managers, etc.). This includes active participation in interdisciplinary meetings in acute or post-acute settings.• Provide authorizations to contracted facilities in accordance with health plan contracts or facilitate obtaining letter of agreements as needed.
• Facilitates repatriation of out-of-network patients and escalates as needed when there is a delay in repatriation. Case Management:• Identify and refer patients to Sutter’s Value Based Case Management team as appropriate (includes complex case management, transitions of care, disease or population case management, etc.).
Delegated Health Plan Contract Implementation:• Comply with health plan and regulatory prior authorization turnaround timeframes.
•Comprehension of health plan contracts (i.e. scope of authorization, division of financial responsibility, carve-outs, risk and shared risk arrangements, etc.).
LSI20668
Established in 2000, LanceSoft is a Certified MBE and Woman-Owned organization. Lancesoft Inc. is one of the highest rated companies in the industry. We have been recognized as one of the Largest Staffing firms and ranked in the top 50 fastest Growing Healthcare Staffing firms in 2022. Lancesoft offers short- and long-term contracts, permanent placements, and travel opportunities to credentialed and experienced professionals throughout the United States. We pride ourselves on having industry leading benefits. We understand the importance of partnering with an expert who values your needs, which is why we’re 100% committed to finding you an assignment that best matches your career and lifestyle goals. Our team of experienced career specialists takes the time to understand your needs and match you with the right job Lancesoft has been chosen by Staffing Industry Analysts as one of the Best Staffing Firms to Work for.LanceSoft specializes in providing Registered Nurses, Nurse Practitioners, LPNs/LVNs, Social Workers, Medical Assistants, and Certified Nursing Assistants to work in Acute Care Centers, Skilled Nursing Facilities, Long-Term Care centers, Rehab Facilities, Behavioral Health Centers, Drug & Alcohol Facilities, Home Health & Community Health, Urgent Care Clinics, and many other provider-based facilities.