Job Description

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Case Manager, UR is responsible for overseeing the daily operations of the assigned caseload. Ensures Medical Necessity for patient admission and concurrent stay at the short-term acute hospital level of care are met, utilizing the facility approved non-MD reviewer guidelines. Communicates as appropriate to the payer. Refers all cases not meeting MN for second level review. Ensures a safe and timely discharge / transition to the next appropriate level of care.  Ensures timely escalation of unresolved care coordination issues to the appropriate level/entity. Enters delays in service and avoidable days regarding exceeded payer LOS variances. Communicates denials and physician related utilization management practices to immediate supervisor same day as identified.  Keeps facility administration and CM Manager / Director of Utilization Management aware of any daily operational / physician related issues.  Works closely with the facility Physician Advisor and Corporate. Works collaboratively with health care team, patients and families, administration and members of the Medical Staff.  Responsible for active participation in daily weekday intra disciplinary patient rounding. 

• Completes TAR for assigned Medi-Cal patient population/ obtains authorizations for managed care accounts and submits appeals for all denied cases. Maintains confidentiality of all information according to Hospital Policy and Procedure and legal and regulatory requirements.
• Reviews hospital admissions and continued stays in accordance with procedures, criteria, and standards approved by the medical staff. Identifies opportunities for improvement in the current processes and procedures.  Escalates unresolved issues to direct supervisor of UM Facility Administrator per escalation process.
• Collaborates with Social Services, Clinical Team, patient and families to prepare patient’s discharge planning needs. Oversees appropriate DC documentation. Works with Social Service   to perform a variety of miscellaneous services, such as arranging for discharge or post-hospital plans, placement of patients in skilled nursing facilities or board an care homes.
• Collects and reports data for quality assessment/improvement activities. Maintains good rapport and open communication with CM staff, Medical Staff, internal and external customers.
• Oversees that patients and their significant others understand medical recommendations through individual or group conferences. Supports patient rights and patient choice.

Minimum Education: None. 

Minimum Experience: Two (2) years of experience in utilization review/management in a managed care or hospital setting required. Knowledge of The Joint Commission and Title XXII regulations. Knowledge of CMS, MCARE, MEDI-CAL and Managed Care Reimbursement. Knowledge in insurance authorization and verification. Knowledge of Interqual and /or Milliman Care criteria. Excellent written and verbal communication skills in English. Computer/EMR Proficiency required. Three (3) years clinical experience in psychiatric hospital setting preferred. Care Management Proficiency with Milliman Care Guidelines or Interqual preferred.

Req. Certification/Licensure: Current Licensure as a Vocational Nurse in the State of California required.

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

• Company 401K
• Medical, dental, vision insurance
• Paid time-off
• Life insurance

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm

Keywords: Case Management, Utilization Review, U.R., Psych, Psychiatric, Psychology, BHU, Behavioral Health