Nursing, Pharmacy, Health Services - Registered Nurse Senior Registered Nurse Senior
Company: Aditi Consulting
Location: Rancho Cordova
Posted on: January 26, 2023
Researches and designs treatment /care plans to promote quality of
care, cost effective health care services based on medical
necessity complying with contract for each appropriate plan
Implements discharge (DC) planning activities for medically complex
Determines appropriateness of referral for CM services.
Provides Referrals to Quality Management (QM), Disease Management
(DM) and Appeals and Grievance department (AGD).
Conducts member care review with medical groups or individual
providers for continuity of care, out of area/out of network and
Manages member treatment in order to meet recommended length of
stay. Ensures DC planning at levels of care appropriate for the
members needs and acuity.
Negotiates with employer groups when contractually required.
Assesses members health behaviors, cultural influences and clients
Evaluates all information related to current/proposed treatment
plan and in accordance with clinical practice guidelines to
identify potential barriers.
Researches opportunities for improvement in assessment methodology
and actively promotes continuous improvement.
Anticipates potential barriers while establishing realistic goals
to ensure success for the member, providers and BSC.
Determines realistic goals and objectives and provides appropriate
alternatives. Actively solicits clients involvement.
Designs appropriate and fiscally responsible plan of care with
targeted interventions that enhance quality, access and
Adjusts plans or creates contingency plans as necessary.
Assesses and re-evaluates health and progress due to the dynamic
nature of the plan of care required on an ongoing basis.
Initiates and implements appropriate modifications in plan of care
to adapt to changes occurring over time and through various
Develops appropriate and fiscally responsible plan of care with
targeted interventions that enhance quality, access, and
Recognizes need for contingency plans throughout the healthcare
Develops and implements the plan of care based on accurate
assessment of the member and current or proposed treatment
Assists with precepting responsibilities for new hires and auditing
Current CA RN License. Bachelors of Science in Nursing or advanced
Two years experience in Behavioral Health, Mental Health or
Substance Use Disorder
Certified Case Manager (CCM) or is in process of completing
certification when eligible based on CCM application
Demonstrated ability to independently assess, evaluate, and
interpret clinical information and care planning.
In depth understanding of community resources, treatment options,
home health, funding sources and special programs.
Extensive knowledge of evidenced based clinical practice guidelines
particularly for chronic conditions.
Incorporates professional judgment and critical thinking when
determining medical necessity that promotes quality, cost-effective
Working knowledge of regulatory and accreditation standards
preferred (URAC, NCQA, DMHC, Case Management Society of America
Knowledge of Coordination of Care, Medicare regulations, prior
authorization, level of care and length of stay criteria sets
Demonstrated and evolving competence in CM functions and standards
If certified as a CM, maintains CCM certification through
continuing competence and education appropriate to case management
scope of practice.
Monitors Clinical Support Coordinators (non-clinical) in the
performance of UM support activities.
QA and regular performance audits.
Keywords: Aditi Consulting, Rancho Cordova , Nursing, Pharmacy, Health Services - Registered Nurse Senior Registered Nurse Senior, Healthcare , Rancho Cordova, California
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