Job Title: Case Management Nurses 

                (Telephonic & On-Site)

Department: UTILIZATION MANAGEMENT/QUALITY MANAGEMENT

Reports To: UM Manager

Job Title: QM Nurse

Department: QUALITY MANAGEMENT

Reports To: Chief Nursing Officer

 

POSITION SUMMARY

 

To provide clinical support for the Quality Management Program and the department in meeting compliance with NCQA standards and Health Plan contract requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To investigate, analyze, and prepare appeals and grievances for review and subsequently provide response to requesting parties.

To investigate, gather medical records and prepare potential quality of care cases requiring peer review.

To coordinate and collect medical records for the HEDIS project based upon Health Plan requirements.

To prepare agendas and minutes for QMC as necessary.

To assist in annual review and revision of the following QM documents: QM program description, workplan, program evaluation, and policies and procedures.

To prepare monthly, quarterly, and annual reports on appeals, grievances, and quality of care cases as required by Health Plan contracts and QMC.

To provide education to other departments on QM processes as necessary.

To review and analyze statistical reports for trends and/or patterns, and recommend corrective action plans.

To coordinate review with QMC Chairperson, Medical Director, and UM staff, as indicated.

Supports credentialing process through quality review and documentation of physician profiling.

Maintains organized hard copy records and files.

To assist in review of MBOC Hot Sheet provider listing.

To assist in the data entry of MBOC providers to a log for monitoring purposes.

Attends monthly QM Committee meetings.

To demonstrate professionalism through compliance with the company dress code and attendance policies.

To comply with department policy on confidentiality and storage of medical information.

To perform other duties as assigned by supervisor.

To contribute to a fair, confidential, and positive work environment.

 

QUALIFICATIONS

Education: Clinical licensure as LVN/RN with an Associate/Bachelors Degree or equivalent years of experience in Managed Care

Licensure: Must possess current California Registered Nurse or LVN license

Experience: Requires extensive and specialized knowledge in the area of managed care as is generally acquired by 3 or more years of experience in either a physician group setting or Health Plan.

Requires specialized knowledge in the area of quality management as is generally acquired by 2 or more years of experience in QM with a Health Plan, IPA, or medical group.

Requires specialized knowledge as is generally acquired by an undergraduate or advanced degree in health care, nursing, or a related field.

Requires extensive clinical nursing skills as is generally acquired by 5 or more years of experience in either an acute care hospital or a clinic setting.

Abilities: Strong computer skills in word processing and spreadsheet programs.

Excellent oral and written communication skills.

 

 

 

JOB DESCRIPTION

 

Job Title:                Case Management Nurses (Telephonic &  

                              On-Site)           

Department:            UTILIZATION MANAGEMENT/QUALITY MANAGEMENT

Reports To:            UM Manager

 

 

POSITION SUMMARY

 

Responsibilities include the maintenance of beddays/1000 within the La Vida benchmark and utilization of contracted facilities and providers. 

ESSENTIAL DUTIES AND RESPONSIBILITIES

·        Document DCP on initial review and update as necessary.

·        Provide concurrent review of all patients receiving care in acute care hospitals, psychiatric facilities and skilled nursing facilities for appropriateness and medical necessity. 

·        Ensure use of contracted providers and facilities.

·        Ensure approval and/or denial of acute and SNF inpatient stay within 24 hr notice of admission.

·        Assist Hospitalist or attending in timely transfers of patients admitted out of network.

·        Serve as a resource to the La Vida staff for UM related issues.

·        Provide authorization of DCP services such as home health and DME, verify and document benefits.

·        Assist in the retrospective review of unauthorized services/claims for payment based upon UM Criteria and department Policy & Procedures.

·        Participate in the gathering and review of retrospective UM studies illustrating La Vida  utilization patterns and the development of appropriate action plans aimed at quality improvement in identified areas.

·        Serve as a liaison between La Vida’s UM chairman, health plan and hospital case managers as necessary.

·        Assist in improving acute and SNF beddays/1000 through concurrent review and coordination of care with the CMO to meet the department targets.

·        Assist as necessary in training new case managers

·        Assist in Quality by reporting inpatient adverse outcome cases.

·        Prepares and participates in daily bedday rounds and provides accurate information

·        Ensures medical director is involved in review of cases in which discharge is delayed.

·        Additional responsibilities for on-site case managers:

o       Coordinate daily rounds with hospitalist

o       Comply with all hospital requirements for on-site review

o       Participation in case conferences as necessary

o       Communicate with family and patient regarding discharge plan and any denial

QUALIFICATIONS   

Education:        Nursing  Degree, plus  university program certificate, or one to two  years related experience and/or training; or equivalent combination of education and experience.

Licensure:         Must possess current California Registered Nurse or LVN license

Experience:      One or two year experience on case management

Abilities:           Coordinate member’s care including discharge planning

                        Trouble shoot all related UM issues

                        Authorize ambulatory care referrals

                        Good communication skills with

                        Respond effectively to the most sensitive inquiries and complaints by members, providers and health plans

                        Apply principles of logical, scientific and/or medical thinking to a wide range of intellectual and practical problems

                        Trouble shoot all related UM issues  

 

 

 

JOB DESCRIPTION

 

Job Title:                Assistant, Human Resources

Department:            Human Resources

Reports To:            Director, Human Resources

 

POSITION SUMMARY

 

Provides support to Human Resources by performing a variety of technical clerical duties related to maintenance of personnel and payroll records, files and systems.

PRINCIPAL DUTIES AND RESPONSIBLITIES

 

• Assist in answering phones and greeting visitors to Human Resources department.
• Provide information regarding current job openings to all interested parties, direct visitors to other offices as appropriate, assist prospective employees in completing application process.
• Process employment applications and schedule interviews.
• Perform pre-employment background checks.
• Support new hire process, pre-employment physicals and drug screens, conduct new hire orientation, distribute health & welfare enrollment information.
• Monitor, initiate and track annual and probationary evaluation process.  
• Payroll processing.
• Update payroll & personnel data in HRIS system each payperiod which includes but is not limited to new hires, terminations, retirements, promotions, demotions, leaves of absence, benefit changes, deduction changes, tax changes, address changes.
• Monitor and update electronic timekeeping system.
• Maintenance of personnel and payroll files.
• Preparation of reports as directed.
• All other duties as assigned.

 

OTHER DUTIES AND RESPONSIBILITIES

 

Demonstrates understanding of policies and procedures:

1.      Observes all policies and procedures for use of timekeeping system, including attendance, tardiness, proper clocking procedure, overtime authorization, and that ID badge is clearly visible.  No more than 3 valid complaints per year.

2.      Observes rules and regulations for mandatory requirements including licensure, fire,

       disaster, and physical examinations as established by policy.

3.      Consistently maintains appearance and dress standards that are appropriate, safe, and in accordance with department standards with no more than 2 valid complaints per year.

4.      Attends at least 75% of staff meetings per year.

Interacts with patients, physicians, staff and visitors in ways that demonstrate caring and reflect the La Vida missions and philosophy:

1.      Proficient in creating positive telephone communication by:

                        Answering the telephone by the third ring.

                        Identifying self to others when speaking or answering the telephone.

                        Listening attentively; asking questions for clarification; offering/seeking assistance.

2.      Proficient in creating a supportive climate by:

                        Allowing patient and/or family members to verbalize their concerns.

                        Concluding all interactions on a positive and encouraging note.

3.      Proficient in quality guest relations by:

                        Repeating key information to ensure accuracy.

                        Giving information clearly, concisely and calmly.

                        Offering assistance.

                        Calling patient/guest by proper name.

4.      Assist in enforcing compliance.

 

QUALIFICATIONS

 

Education                     High School Graduate, plus two years general education at an accredited college.

 

Experience                   Previous work in an administrative support function.

 

Abilities                        Ability to understand State and Federal employment law and basic principles and practices of human resource administration. Strong communication in written and verbal form.  Interpersonal and presentation skills.  Proficient at operating a personal computer and peripheral equipment.  Knowledge of Microsoft Office programs such as Word and Excel.  Maintain confidentiality of privileged information obtained in the course of work.

 

 

 

 

 

JOB DESCRIPTION

 

Job Title:                Medical Receptionist

Department:            Clinical Operations

Reports To:            Clinic Manager

 

POSITION SUMMARY

 

Present a professional image of attentiveness, respect and promptness in responding to all visitors entering the reception area and all callers requesting information about the facility.

PRINCIPAL DUTIES AND RESPONSIBLITIES

 

• Greet patients and visitors at the reception desk.
• Handle heavy telephone contact, answering and directing calls.
• Check in patients and verify eligibility with health plan.
• Assist patients with form completion.
• Ensure that each patient is given HIPAA regulations, Patient Rights, and Arbitration agreements.
• Collect copayments and post to patient account, generate receipts for patient.
• Open and close daily receipt batches.
• Make new patient charts.
• Update patient information at every visit
• All other duties as assigned.

 

OTHER DUTIES AND RESPONSIBILITIES

 

Demonstrates understanding of policies and procedures:

1.      Observes all policies and procedures for use of timekeeping system, including attendance, tardiness, proper clocking procedure, overtime authorization, and that ID badge is clearly visible.  No more than 3 valid complaints per year.

2.      Observes rules and regulations for mandatory requirements including licensure, fire,

       disaster, and physical examinations as established by policy.

3.      Consistently maintains appearance and dress standards that are appropriate, safe, and in accordance with department standards with no more than 2 valid complaints per year.

4.      Attends at least 75% of staff meetings per year.

 

Interacts with patients, physicians, staff and visitors in ways that demonstrate caring and reflect the La Vida missions and philosophy:

   

1.      Proficient in creating positive telephone communication by:

                        Answering the telephone by the third ring.

                        Identifying self to others when speaking or answering the telephone.

                        Listening attentively; asking questions for clarification; offering/seeking assistance.

2.      Proficient in creating a supportive climate by:

                        Allowing patient and/or family members to verbalize their concerns.

                        Concluding all interactions on a positive and encouraging note.

3.      Proficient in quality guest relations by:

                        Repeating key information to ensure accuracy.

                        Giving information clearly, concisely and calmly.

                        Offering assistance.

                        Calling patient/guest by proper name.

4.      Assist in enforcing compliance.

 

QUALIFICATIONS

 

Education                     High School diploma or general education degree (GED).

 

Certificates,                   None

Licenses,                     

Registrations

                                   

Experience                   Six months to one year related experience and/or training.

 

Abilities                        Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.  Ability to interact with a large volume of callers and impart accurate information on diverse and changing resources.  Ability to enunciate clearly by phone and in person.