Nursing, Pharmacy, Health Services - Registered Nurse Senior Registered Nurse Senior

Company: Aditi Consulting
Location: Rancho Cordova
Posted on: January 26, 2023

Job Description:

Job Description

Responsibilities:
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 type.
Implements discharge (DC) planning activities for medically complex cases.
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 investigational/experimental cases.
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.

Assessment:
Assesses members health behaviors, cultural influences and clients belief/value system.
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.

Planning:
Designs appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes.
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 settings.
Develops appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
Recognizes need for contingency plans throughout the healthcare process.
Develops and implements the plan of care based on accurate assessment of the member and current or proposed treatment plan.
Assists with precepting responsibilities for new hires and auditing efforts.

Education/Requirements:
Current CA RN License. Bachelors of Science in Nursing or advanced degree preferred
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 requirements.
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 care.
Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, Case Management Society of America CMSA)
Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable.
Demonstrated and evolving competence in CM functions and standards of practice.
If certified as a CM, maintains CCM certification through continuing competence and education appropriate to case management scope of practice.

Supervisory Responsibilities:
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