Registered Nurse /Utilization Care Manager Job in El Dorado Hills, CA
Location: El Dorado Hills
Posted on: February 11, 2024
Modis is looking to fill a Nursing/Utilization Care Manager
contract with likelihood to extend, with our healthcare client in
El Dorado Hills, CA. If you meet the below requirements and would
like to learn more about this great opportunity please apply now
for immediate consideration.
We are looking for a Nurse/Case Manager familiar with performing
advanced or complicated case review and determining first level
approvals for prior authorization of services, inpatient,
outpatient and/or ancillary services. You will act as liaison
between the member, the provider and the health plan to utilize
appropriate and cost effective resources. Ultimate goal is
Discharge (DC) planning and to return patient to cognitive and
physical condition prior to event that triggered treatment.
- Requires extensive experience in nursing, 2-3 years acute
clinical experience and 3 years utilization management
- Computer proficiency, Microsoft Office, Outlook, Excel,
- Performs prospective, concurrent and retrospective
utilization reviews and first level determination approvals for
- Determines discharge (DC) plan by assessing cognitive and
physical status. Determines post-acute needs of patient, levels of
- Triages and prioritizes cases to meet required
turn-around times. Expedites access to appropriate care for members
with urgent needs using expedited review process.
- Develops and reviews member centered documentation and
correspondence reflecting determinations in compliance with
regulatory and accreditation standards.
QUALIFICATIONS/ JOB REQUIREMENTS
- Current active CA RN License required. Bachelors of
Science Degree in Nursing preferred.
- Proficient knowledge of NCQA, URAC, federal and state
- Knowledge of Coordination of Care, Medicare regulations,
prior authorization, level of care and length of stay criteria sets
- Demonstrates professional judgment, and critical
thinking, to promote the delivery of quality, cost-effective care.
This judgment is based on medical necessity including intensity of
service and severity of illness within contracted benefits and
appropriate level of care.
Keywords: , Sacramento , Registered Nurse /Utilization Care Manager Job in El Dorado Hills, CA, IT / Software / Systems , El Dorado Hills, California
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