Out Of Network Utilization Management RN
Company: Dignity Health
Location: Rancho Cordova
Posted on: June 20, 2022
**Out Of Network Utilization Management RN**
Mercy Healthcare SacramentoRancho Cordova, California
**Requisition ID** 2022-243962 **Employment Type** Full Time
**Department** Care Coordination **Hours/Pay Period** 80 **Shift**
Day **Weekly Schedule** Monday - Friday (8:00 AM - 5:00 PM)
**Remote** No **Category** Case Management and Social Work
Dignity Health is one of the nation's largest health care systems.
As of June 30, 2017, Dignity Health operated more than 400 care
centers, including hospitals, urgent and occupational care, imaging
and surgery centers, home health, and primary care clinics in 22
states, through its network of more than 9,000 physicians and more
than 60,000 employees. Headquartered in San Francisco, CA, Dignity
Health is dedicated to providing compassionate, high-quality, and
affordable patient-centered care with special attention to those
who are poor and underserved. In its fiscal year ended June 30,
2017, Dignity Health provided $2.6 billion in charitable care and
services. More information on Dignity Health is available at
**Job Summary** **:**
This position is responsible for improving care management
coordination between SSJSA hospital staff and affiliated medical
groups and IPA's by using advanced problem-solving skills,
consultation, communication, personal education, and research. This
position is also responsible for providing oversight for
out-of-network (OON) cases that are capitated to the Dignity Health
hospitals in the GSSJSA and to provide support to the Director,
Clinical Partnerships related to managing GSSJSA capitated
business. This position works with affiliated GSSJSA Medical Groups
and IPA's to meet appropriate quality, patient satisfaction, and
utilization objectives in a manner consistent with the Mission and
Philosophy of DH.
Dignity Health is committed to showing respect for all people by
providing excellent care. That means utilizing the most advanced
medical technology. It means working closely with our patients so
they can lead healthy, meaningful lives. And, of course, it means
doing all of this with compassion - the kind of compassion that
includes finding ways to deliver high quality care at the lowest
possible cost, so it's accessible to all.
**Planning and Managing**
--- Locate and coordinate care for Dignity Health members who are
in the Emergency room or hospitalized inpatients outside the
Dignity Health system.
--- Locate and coordinate resources for members who are returning
to the Dignity Health system (repatriation).
--- Coordinate care on complex cases where hospital and/or medical
group are at risk.
--- Measure performance of case management for the high risk and
high opportunity patients.
--- Identifies complex/problematic system issues related to care
management and involves the multidisciplinary team to improve
quality and appropriate resource allocation.
--- Collaborates with Case Management Leadership in maintaining
compliance with requirements of regulatory agencies.
--- Provide monthly and or quarterly reports related to out of
network (OON) utilization with comparison to objectives for all
affiliated medical groups.
--- Share monthly and/or quarterly reports related to OON
utilization with appropriate affiliated medical groups and as
appropriate interact with Joint Operating Committees to meet
--- In collaboration with the Director, Clinical Partnerships,
develops and implements programs to enhance the quality and profit
margins of the organization.
--- Focuses on high volume, high risk patient populations and/or
DRG groups to identify opportunities to improve patient outcomes
and reduce unnecessary resource utilization.
--- Assesses cases and contracts utilizing knowledge of current
legal, accreditation, and regulatory requirements.
--- Accurately communicates with providers about the diagnosis and
severity of illness to determine appropriate levels of care.
--- Coordinates transfers via DH transfer center of out of network
capitated patients to the appropriate level of care.
--- Coordinates concurrent review for patients at non DH facilities
with affiliated medical groups to reduce out of network expenses
--- Assists in verifying case data for each facility to provide
correct medical group risk payment and prevent discrepancies.
--- In conjunction with the Medical Directors of medical
group/IPA/health plan, provide information to case management for
OON patients in need of care post hospitalization.
--- Provide daily/weekly/monthly OON reports/updates to Director,
Clinical Partnerships and others as required for analysis at
Purchased Services Committee, Steering Committee and other
utilization management committees as needed.
**Analysis and Reporting**
--- Provide leadership for assigned projects by means of expert and
research based knowledge and achieve agreed upon outcomes.
--- Collaborate with hospital case management to implement and
maintain processes for regulatory compliance.
--- Integrate quality improvement processes within case management
--- Monitors and updates current data collection activities.
--- Monitors open issues from all activities, groups and
--- Provide a consultative relationship with affiliated medical
group and IPA care management personnel and management focusing on
mobilizing internal and external resources to solve problems
through planned change.
--- Applies utilization management skills in day to day reviews
using approved medical necessity criteria.
**Communicating and Training**
--- Collaborate with all levels of the health care team to support
and contribute to management/organizational goals for quality
--- Communication to DH transfer center of patients stable for
re-patriation into a DH facility from various sources, ED, NICU,
trauma, med-surg, pediatrics etc. in a timely manner taking into
consideration appropriate resource utilization.
--- Keep abreast of the continually changing regulations affecting
the industry to facilitate improving the quality of services
--- Work closely with affiliated IPA and Medical Group Medical
Directors and key physician leaders (i.e trauma, NICU, pediatrics)
to identify needed changes in practice and/or referral patterns and
to assist in their modification to achieve desired outcomes.
--- Communicates progress and challenges to Director, Clinical
Partnerships and other members of DH utilization management
Experience: JCAHO and State and Federal Regulations. Coding,
documentation, DRG's. Case Management models and standards. Nursing
theory and practice standards. Research models. Continuous quality
improvement methods. Knowledge of reimbursement under Medicare,
MediCal and private insurance, Capitation including Medical
group/physician implication. Case management of capitated at-risk
patients. Knowledge of the meeting process.
--- Current California nursing licensure.
--- Five years of experience in utilization review and discharge
planning, case management and managed care.
--- A baccalaureate degree in nursing, business or equivalent or a
combination of knowledge and experience that adequately prepares
the individual to competently perform the job
Self-starter and works independently. Organizational and management
skills. Qualitative data collection methodologies and analytical
analysis. Problem solving skills. Effective interpersonal
communication skills. Interpret contracts for benefit analysis as
Must have excellent interpersonal skills to effectively build
relationships within and outside the organization. Has regular
contact with a variety of audiences including front line staff,
management/senior management, physicians and other Dignity Health
Divisions and Corporate staff. Has periodic contact with
representatives of outside agencies.
Reporting Relationships: Reports to Director, Clinical Partnerships
**Travel:** As needed
--- Certification in Case Management
CommonSpirit Health--- is an Equal Opportunity/Affirmative Action
employer committed to
a diverse and inclusive workforce. All qualified applicants will be
employment without regard to race, color, religion, sex, sexual
identity, national origin, age, disability, marital status,
ancestry, veteran status, genetic information, or any other
by law. For more information about your EEO rights as an
CommonSpirit Health--- will not discharge or in any other manner
discriminate against employees or applicants because they have
inquired about, discussed, or disclosed their pay or the pay of
another employee or applicant. However, employees who have access
to the compensation information of other employees or applicants as
a part of their essential job functions cannot disclose the pay of
other employees or applicants to individuals who do not otherwise
have access to compensation information, unless the disclosure is
(a) in response to a formal complaint or charge, (b) in furtherance
of an investigation, proceeding, hearing, or action, including an
investigation conducted by the employer, or (c) consistent with the
contractor's legal duty to furnish information. 41 CFR
External hires must pass a post-offer, pre-employment background
check/drug screen. Qualified applicants with an arrest and/or
conviction will be considered for employment in a manner consistent
with federal and state laws, as well as applicable local
ordinances, ban the box laws, including but not limited to the San
Francisco and Los Angeles Fair Chance Ordinances.
If you need a reasonable accommodation for any part of the
employment process, please contact us by telephone at (415)
438-5575 and let us know the nature of your request. We will only
respond to messages left that involve a request for a reasonable
accommodation in the application process. We will accommodate the
needs of any qualified candidate who requests a reasonable
accommodation under the Americans with Disabilities Act (ADA).
CommonSpirit Health--- participates in E-Verify.
Dignity Health is an Equal Opportunity/ Affirmative Action employer
committed to a diverse and inclusive workforce. All qualified
applicants will be considered for employment without regard to
race, color, religion, sex, sexual orientation, gender identity,
national origin, age, disability, marital status, parental status,
ancestry, veteran status, genetic information, or any other
characteristic protected by law.
Keywords: Dignity Health, Rancho Cordova , Out Of Network Utilization Management RN, Executive , Rancho Cordova, California
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