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Patient Care Coordinator opportunity in San Jose, CA!

DEPARTMENT: Utilization Mgt.SCHEDULE: Part-Time Regular, 24 hours per week, Day shift: 8:00am to 5:00pm. Works every other Weekend, and the days, and hours will vary.EDUCATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Master´ Degree preferred.LICENSE/CERTIFICATION: Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required.JOB SUMMARY: Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the healthcare team.QUALIFICATIONS: Experience (usually 2+ years) in direct patient care delivery and management. Demonstrated experience in utilization review, case management, and discharge planning preferred (usually 2+years). Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA, HIPPA, ERISA,EMTALA and all other applicable federal/state/local laws and regulations. Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities. Fundamental word processing and computer navigation skills and the ability to interpret and use analytic data in day to day operations. Knowledge of healthcare benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.) DUTIES:Utilization Management Performs daily preadmission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge. Escalates utilization and system problems which have not been resolved at the local level to the next level (RM/UM Director, CCL, DHO, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams. Educates other healthcare team members on utilization and cost containment initiatives. Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care).Discharge Planning Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, another healthcare providers and agencies. Performance Improvement Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols. Participates in the development and implementation of guidelines, preprinted physician orders, care paths, etc. for patient care. Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Develops, collects, trends, and analyzes data relevant tithe utilization of healthcare resources including avoidable/variance days, readmissions, one-daystars, DRGs, LOS, etc. Participates in the development, implementation, communication, maintenance and monitoring of local UM Work plan initiatives. Administrative and Regulatory Shares accountability with the UM Manager for planning, developing, and managing the department budget. Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff. Provides input into the performance evaluations of team members. May plan and control work assignments and special projects of team members. Assists in developing, implementing and maintaining utilization management policies and procedures. Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements.Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Consistently supports compliance and the Principles of Responsibility (KP’s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.PLEASE NOTE: - Kaiser Permanente is an AA/EEO employer -

This position supports Kaiser Permanente´s code of conduct and compliance by adhering to all laws and regulations, accreditation and Licensure requirements, and internal policies and procedures. Kaiser Permanente is an AA/EEO employer.DEPARTMENT: Continuity of CareSCHEDULE: Part-time, regular; 28hrs/week; SHIFT: Day; Sunday through Saturday (Varied)EDUCATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Masters Degree preferred. Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required. PHN preferred.POSITION SUMMARY: Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the health care team.QUALIFICATIONS: Experience (usually 2+ years) in direct patient care delivery and management. Demonstrated experience in utilization review, case management, and discharge planning preferred (usually 2+ years). Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA,HIPPA, ERISA, EMTALA and all other applicable federal/state/local laws and regulations. Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities. Fundamental word processing and computer navigation skills, and the ability to interpret and use analytic data in day to day operations. Knowledge of healthcare benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.).REQUIRED SKILLS TESTING: N/ADUTIES: Utilization Management - Performs daily preadmission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge. Escalates utilization and system problems which have not been resolved at the local level to the next level (RM/UM Director, CCL, DHO, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams. Educates other healthcare team members on utilization and cost containment initiatives. Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care).Discharge Planning - Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other healthcare providers and agencies. Performance Improvement - Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols. Participates in the development and implementation of guidelines, preprinted physician orders, care paths, etc. for patient care. Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, DRGs, LOS, etc. Participates in the development, implementation, communication, maintenance and monitoring of local UM Workplan initiatives. Administrative and Regulatory - Shares accountability with the UM Manager for planning, developing, and managing the department budget. Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff. Provides input into the performance evaluations of team members. May plan and control work assignments and special projects of team members. Assists in developing, implementing and maintaining utilization management policies and procedures. Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements (see qualifications).Consistently supports compliance and the Principles of Responsibility (KP´s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures.

PT Patient Care Coordinator- NICU or Adult

This position supports Kaiser Permanente´s code of conduct and compliance by adhering to all laws and regulations, accreditation and Licensure requirements, and internal policies and procedures. Kaiser Permanente is an AA/EEO employer.DEPARTMENT: Continuity of CareSCHEDULE: Part-time, regular; 24hrs/week; SHIFT: Day; Sunday through Saturday (Varied)EDUCATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Masters Degree preferred. Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required. PHN preferred.POSITION SUMMARY: Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the health care team.QUALIFICATIONS: Experience (usually 2+ years) in direct patient care delivery and management. Demonstrated experience in utilization review, case management, and discharge planning preferred (usually 2+ years). Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA,HIPPA, ERISA, EMTALA and all other applicable federal/state/local laws and regulations. Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities. Fundamental word processing and computer navigation skills, and the ability to interpret and use analytic data in day to day operations. Knowledge of healthcare benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.).PREFERRED QUALIFICATIONS: Experience with discharge planning and/or utilization management in the NICU preferred.REQUIRED SKILLS TESTING: N/ADUTIES: Utilization Management - Performs daily preadmission, admission, and concurrent utilization reviews using guidelines institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge. Escalates utilization and system problems which have not been resolved at the local level to the next level (RM/UM Director, CCL, DHO, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams. Educates other healthcare team members on utilization and cost containment initiatives. Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care).Discharge Planning - Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other healthcare providers and agencies. Performance Improvement - Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols. Participates in the development and implementation of guidelines, preprinted physician orders, care paths, etc. for patient care. Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, DRGs, LOS, etc. Participates in the development, implementation, communication, maintenance and monitoring of local UM Workplan initiatives.Administrative and Regulatory - Shares accountability with the UM Manager for planning, developing, and managing the department budget. Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff. Provides input into the performance evaluations of team members. May plan and control work assignments and special projects of team members. Assists in developing, implementing and maintaining utilization management policies and procedures. Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements (see qualifications).Consistently supports compliance and the Principles of Responsibility (KP´s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures.

This position supports Kaiser Permanente´s code of conduct and compliance by adhering to all laws and regulations, accreditation and Licensure requirements, and internal policies and procedures. Kaiser Permanente is an AA/EEO employer.DEPARTMENT: Continuity of CareSCHEDULE: Part-time, regular; 24hrs/week; SHIFT: VariableEDUCATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Masters Degree preferred. Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required.POSITION SUMMARY: Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the health care team.QUALIFICATIONS: Experience (usually 2+ years) in direct patient care delivery and management. Demonstrated experience in utilization review, case management, and discharge planning preferred (usually 2+ years). Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA,HIPPA, ERISA, EMTALA and all other applicable federal/state/local laws and regulations. Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities. Fundamental word processing and computer navigation skills, and the ability to interpret and use analytic data in day to day operations. Knowledge of healthcare benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.).Preferred Qualifications: Must have knowledge of InterQual. Must be assertive in applying and implementing these guidelines.REQUIRED SKILLS TESTING: N/ADUTIES: Utilization Management - Performs daily preadmission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge. Escalates utilization and system problems which have not been resolved at the local level to the next level (RM/UM Director, CCL, DHO, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams. Educates other healthcare team members on utilization and cost containment initiatives. Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care).Discharge Planning - Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other healthcare providers and agencies. Performance Improvement - Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols. Participates in the development and implementation of guidelines, preprinted physician orders, care paths, etc. for patient care. Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, DRGs, LOS, etc. Participates in the development, implementation, communication, maintenance and monitoring of local UM Work plan initiatives. Administrative and Regulatory - Shares accountability with the UM Manager for planning, developing, and managing the department budget. Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff. Provides input into the performance evaluations of team members. May plan and control work assignments and special projects of team members. Assists in developing, implementing and maintaining utilization management policies and procedures. Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements (see qualifications).Consistently supports compliance and the Principles of Responsibility (KP´s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures.

Advocate Health Care is currently seeking candidates for a Quality Improvement- QI position.

This position is responsible for enhancing patient care and satisfaction through quality activity, monitoring and to coordinate and execute the specific tasks required for efficient and effective operation of the quality improvement program in accordance with department, contractual and regulatory agency standards.Qualifications: Good organizational and interpersonal skills.Computer skills, basic keyboard knowledge. Willingness to be flexible with work scheduleKnowledge of managed care or utilization review or hospital quality. BSN or 2-4 equivalent years experience in managed care.1-2 years experience in utilization management/QI activity. 3-5 years of clinical experienceCurrent RN license issued by the state of IllinoisCurrent CPR certificationAdvocate Health Care, based in Oak Brook, Illinois, is the largest fully integrated health care delivery system in metropolitan Chicago and the state of Illinois, and is recognized as one of the top health care systems in the country. Advocate is the second largest private sector employer in metropolitan Chicago with more than 25,000 associates and has the largest trauma network in the state of Illinois.

DEPARTMENT: Utilization ManagementSCHEDULE: On call, 0 hours/week, Day shift including weekends and holidays.EDUCATION/LICENSE/CERTIFICATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Masters Degree preferred. Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required.JOB SUMMARY: Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the healthcare team.QUALIFICATIONS: Experience (usually 2+ years) in direct patient care delivery and management. Demonstrated experience in utilization review, case management, and discharge planning preferred(usually 2+ years). Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA,HIPPA, ERISA, EMTALA and all other applicable federal/state/local laws and regulations. Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities. Fundamental word processing and computer navigation skills, and the ability to interpret and use analytic data in day to day operations. Knowledge of healthcare benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.).DUTIES: Utilization Management Performs daily preadmission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge. Escalates utilization and system problems which have not been resolved at the local level to the next level (RM/UM Director, CCL, DHO, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams. Educates other healthcare team members on utilization and cost containment initiatives. Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care).Discharge Planning Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing , social services, and other healthcare providers and agencies. Performance Improvement Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols. Participates in the development and implementation of guidelines, preprinted physician orders, care paths, etc. for patient care. Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, DRGs, LOS, etc. Participates in the development, implementation, communication, maintenance and monitoring of local UM Work plan initiatives. Administrative and Regulatory Shares accountability with the UM Manager for planning, developing, and managing the department budget. Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff. Provides input into the performance evaluations of team members. May plan and control work assignments and special projects of team members. Assists in developing, implementing and maintaining utilization management policies and procedures. Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements (see qualifications). Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Consistently supports compliance and the Principles of Responsibility (KP´s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.PLEASE NOTE: - Kaiser Permanente is an AA/EEO employer

Patient Care Coordinator

DEPARTMENT: Utilization ManagementSCHEDULE: On call, 0 hours/week, Day shift including weekends and holidays.EDUCATION/LICENSE/CERTIFICATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Masters Degree preferred. Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required.JOB SUMMARY: Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the healthcare team.QUALIFICATIONS: Experience (usually 2+ years) in direct patient care delivery and management. Demonstrated experience in utilization review, case management, and discharge planning preferred(usually 2+ years). Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA,HIPPA, ERISA, EMTALA and all other applicable federal/state/local laws and regulations. Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities. Fundamental word processing and computer navigation skills, and the ability to interpret and use analytic data in day to day operations. Knowledge of healthcare benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.).DUTIES: Utilization Management Performs daily preadmission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge. Escalates utilization and system problems which have not been resolved at the local level to the next level (RM/UM Director, CCL, DHO, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams. Educates other healthcare team members on utilization and cost containment initiatives. Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care).Discharge Planning Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing , social services, and other healthcare providers and agencies. Performance Improvement Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols. Participates in the development and implementation of guidelines, preprinted physician orders, care paths, etc. for patient care. Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, DRGs, LOS, etc. Participates in the development, implementation, communication, maintenance and monitoring of local UM Work plan initiatives. Administrative and Regulatory Shares accountability with the UM Manager for planning, developing, and managing the department budget. Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff. Provides input into the performance evaluations of team members. May plan and control work assignments and special projects of team members. Assists in developing, implementing and maintaining utilization management policies and procedures. Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements(see qualifications).Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Consistently supports compliance and the Principles of Responsibility (KP´s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.PLEASE NOTE: - Kaiser Permanente is an AA/EEO employer

DEPARTMENT: Utilization ManagementSCHEDULE: On call, 0 hours/week, Day shift including weekends and holidays.EDUCATION/LICENSE/CERTIFICATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Masters Degree preferred. Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required.JOB SUMMARY: Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the healthcare team.QUALIFICATIONS: Experience (usually 2+ years) in direct patient care delivery and management. Demonstrated experience in utilization review, case management, and discharge planning preferred (usually 2+ years). Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA,HIPPA, ERISA, EMTALA and all other applicable federal/state/local laws and regulations. Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities. Fundamental word processing and computer navigation skills, and the ability to interpret and use analytic data in day to day operations. Knowledge of healthcare benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.).DUTIES: Utilization Management Performs daily preadmission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge. Escalates utilization and system problems which have not been resolved at the local level to the next level (RM/UM Director, CCL, DHO, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams. Educates other healthcare team members on utilization and cost containment initiatives. Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care). Discharge Planning Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing , social services, and other healthcare providers and agencies. Performance Improvement Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols. Participates in the development and implementation of guidelines, preprinted physician orders, care paths, etc. for patient care. Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, DRGs, LOS, etc. Participates in the development, implementation, communication, maintenance and monitoring of local UM Work plan initiatives. Administrative and Regulatory Shares accountability with the UM Manager for planning, developing, and managing the department budget. Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff. Provides input into the performance evaluations of team members. May plan and control work assignments and special projects of team members. Assists in developing, implementing and maintaining utilization management policies and procedures. Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements(see qualifications). Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Consistently supports compliance and the Principles of Responsibility (KP´s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.PLEASE NOTE: - Kaiser Permanente is an AA/EEO employer

Patient Care Coordinator opportunity in San Jose, CA!

DEPARTMENT: Utilization Mgt.SCHEDULE: Part-Time Regular, 32 hours per week, Day shift. Monday through Thursday: 8:00am to5:00pm. Works every other Weekend, and the days, and hours will vary.EDUCATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Masters Degree preferred.LICENSE/CERTIFICATION: Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required.JOB SUMMARY: Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the healthcare team.QUALIFICATIONS: Experience (usually 2+ years) in direct patient care delivery and management. Demonstrated experience in utilization review, case management, and discharge planning preferred (usually 2+years). Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA, HIPPA, ERISA,EMTALA and all other applicable federal/state/local laws and regulations. Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities. Fundamental word processing and computer navigation skills and the ability to interpret and use analytic data in day to day operations. Knowledge of healthcare benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.). DUTIES:Utilization Management Performs daily preadmission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge. Escalates utilization and system problems which have not been resolved at the local level to the next level (RM/UM Director, CCL, DHO, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams. Educates other healthcare team members on utilization and cost containment initiatives. Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care).Discharge Planning Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other healthcare providers and agencies. Performance Improvement Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols. Participates in the development and implementation of guidelines, preprinted physician orders, care paths, etc. for patient care .Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, DRGs, LOS, etc. Participates in the development, implementation, communication, maintenance and monitoring of local UM Work plan initiatives. Administrative and Regulatory Shares accountability with the UM Manager for planning, developing, and managing the department budget. Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff. Provides input into the performance evaluations of team members. May plan and control work assignments and special projects of team members Assists in developing, implementing and maintaining utilization management policies and procedures. Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements (see qualifications).Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Consistently supports compliance and the Principles of Responsibility (KP’s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.PLEASE NOTE: - Kaiser Permanente is an AA/EEO employer -

DEPARTMENT: Utilization Mgt.SCHEDULE: Part-Time Regular, 32 hours per week, Day shift. Monday through Thursday: 8:00am to5:00pm. Works every other Weekend, and the days, and hours will vary.EDUCATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Masters Degree preferred.LICENSE/CERTIFICATION: Graduate of accredited school of nursing, BLS Certification, and current California RN licensure required.JOB SUMMARY: Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the healthcare team.QUALIFICATIONS: Experience (usually 2+ years) in direct patient care delivery and management. Demonstrated experience in utilization review, case management, and discharge planning preferred (usually 2+years). Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA, HIPPA, ERISA,EMTALA and all other applicable federal/state/local laws and regulations. Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities. Fundamental word processing and computer navigation skills and the ability to interpret and use analytic data in day to day operations. Knowledge of healthcare benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.).DUTIES:Utilization Management Performs daily preadmission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge. Escalates utilization and system problems which have not been resolved at the local level to the next level (RM/UM Director, CCL, DHO, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams. Educates other healthcare team members on utilization and cost containment initiatives. Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care).Discharge Planning Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other healthcare providers and agencies. Performance Improvement Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols. Participates in the development and implementation of guidelines, preprinted physician orders, care paths, etc. for patient care .Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, DRGs, LOS, etc. Participates in the development, implementation, communication, maintenance and monitoring of local UM Work plan initiatives. Administrative and Regulatory Shares accountability with the UM Manager for planning, developing, and managing the department budget. Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff. Provides input into the performance evaluations of team members. May plan and control work assignments and special projects of team members Assists in developing, implementing and maintaining utilization management policies and procedures. Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements (see qualifications).Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Consistently supports compliance and the Principles of Responsibility (KP’s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.PLEASE NOTE: - Kaiser Permanente is an AA/EEO employer -

Faulkner Hospital is a 150 bed non-profit, community teaching hospital located in Jamaica Plain, just 3.4 miles from the Longwood medical area, and across the street from the Arnold Arboretum.

Founded in 1900, Faulkner Hospital has a long history of meeting the health care needs of the residents of southwest Boston and surrounding suburbs. We offer comprehensive medical, surgical and psychiatric care as well as complete emergency, ambulatory and diagnostic services. Our largest inpatient services are internal medicine, cardiology, psychiatry, pulmonary, orthopedics, gastroenterology and general/GI surgery. In FY 2005, Faulkner Hospital had over 8,200 discharges and provided ambulatory support services for over 190,000 patient visits.In 1998, Faulkner Hospital, highly regarded as one of the region’s most respected community teaching hospitals, joined with Brigham and Women’s Hospital, one of the country’s leading academic medical centers, to form a common parent company, Brigham and Women’s/Faulkner Hospitals, a member of Partners HealthCare. In early 2001, Brigham and Women’s Hospital affiliated physicians at Harvard Vanguard Medical Associates, a multi-specialty physicians group, began providing primary and secondary care at Faulkner Hospital. Harvard Vanguard Medical Associates is well recognized as a high quality provider of medical care to over 250,000 patients.Faulkner Hospital is an equal opportunity employer dedicated to diversity in all that we do.JOB DESCRIPTION:Improves medical record physician documentation by performing concurrent medical record reviews and addressing incomplete documentation with physicians and other licensed clinicians. Indirectly assures case mix index, DRG assignment and severity/mortality profiles are accurate. Performs concurrent program activities to accomplish and enhance the above. Assists with the appeals process for cases denied coverage by the insurer.--------------------------------QUALIFICATIONS:Registered Nurse with a current license in the state of Massachusetts or a Physician Assistant or a MD Minimum of 6 years of acute medical/surgical clinical experience and familiarly with the area of utilization management--------------------------------

DEPARTMENT:Skilled NursingSCHEDULE:Part-Time regular, 20 hours per week, Vary shift, Monday, Friday - 8:30am - 5:00pm &Wednesday - 8:00am - 12:30pm w / weekend rotation.EDUCATION/LICENSE/CERTIFICATION:BSN or BA in health care related field preferred. Graduate of accredited school of nursing. Current California RN license. PHN preferred. JOB SUMMARY:Conducts utilization review for in-house patients and those members at contracted facilities. Assists in the discharge planning process.QUALIFICATIONS:Previous experience in an inpatient setting (usually 2 years). Previous experience utilization experience required (usually 1 year). Clinical expert in area of review preferred. Demonstrated knowledge of diagnostic codes.PREFERRED QUALIFICATIONS:Previous experience in an inpatient setting (usually 2 years). Previous experience utilization experience required (usually 1 year). Clinical expert in area of review preferred. Demonstrated knowledge of diagnostic codes. Provide clinical oversight for determination of medical necessity for admission to SNF & clinical denials based on medical necessity. Cross train to provide coverage for dept. manager. Cross train for SNF case manager which responsibilities include daily case management of patients while they are in the SNF, working with Kaiser team and contracted SNF team to coordinate needed care, discharge plans, equipment, education, follow-up medical appointments and family interaction and participation in plan of care.Cross train to SNF placement desk working with hospital discharge planners to find an appropriate SNF, secure bed and coordinate patient transfer with discharge planner. This consists of screening referrals for skilled determination, collecting needed documents for placement, coordinate obtaining bed with the SNF vendors and discharge planners, reports on PD placements. Additional responsibilities: create bi-weekly work schedule, reconciliation of Avoidable Days, utilization management reports & appeals processSKILLS TESTING: DUTIES:Conducts utilization review for in-house patients as well as those members who have admitted to contracted facilities. Conducts clinical reviews based on established treatment criteria. Reviews utilization patterns, identifies trends and problems areas for special studies. Assists other healthcare providers in the discharge planning process and triaging on alternative unit of care. Assists in collecting and assimilating clinical data to enhance the quality of services. Generates quality improvement results. Collaborates with physicians on clinical reviews, keeps them appraised of Kaiser clinical criteria. Reports and investigates unusual occurrences and questions inappropriate decisions based on their professional expertise. Interviews patients/caregivers regarding care after hospitalization. Counsels on Medicare and health care plan coverage. Coordinates referrals to appropriate agencies/facilities. OTHER DUTIES:Conducts utilization review for in-house patients and those members at contracted facilities. Assists in the discharge planning process. Conducts utilization review for in-house patients as well as those members who have admitted to contracted facilities. Conducts clinical reviews based on established treatment criteria. Reviews utilization patterns, identifies trends and problems areas for special studies. Assists other health care providers in the discharge planning process and triaging on alternative unit of care. Assists in collecting and assimilating clinical data to enhance the quality of services. Generates quality improvement results. Collaborates with physicians on clinical reviews, keeps them appraised of Kaiser clinical criteria. Reports and investigates unusual occurrences and questions inappropriate decisions based on their professional expertise. Interviews patients/caregivers regarding care after hospitalization. Counsels on Medicare and healthcare plan coverage. Coordinates referrals to appropriate agencies/facilities. Must have experience in skilled nursing facility nursing as well as an understanding of Medicare guidelines for skilled nursing facilities and skilled coverage for care.Case management experience strongly recommended..Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Consistently supports compliance and the Principles of Responsibility (KP�s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.PLEASE NOTE: - Kaiser Permanente is an AA/EEO employer

Established in 1988, Spectrum Healthcare Resources (SHR) has earned a solid reputation in the health care staffing industry.

Position Title / Key Words: Utilization Manager Potential Opening for a permanent position as a Utilization Manager at the Family Health Centers located in Fairfax and Woodbridge, Virginia area. Company Overview: Established in 1988, Spectrum Healthcare Resources (SHR) has earned a solid reputation in the health care staffing industry.  SHR is Joint Commission certified and dedicates itself exclusively to supplying permanent civilian contracted medical professionals for Military Treatment Facilities (MTF) located in the United States. SHR has a unique medical environment, working among the very best medical professionals, and caring for our military family. Job Description: Spectrum Healthcare Resources has a potential opportunity for a Utilization Manager at the Family Health Centers located in Fairfax and Woodbridge, Virginia area.  This permanent civilian contract position offers: - Full Time and Part Time Available - Health, Dental and 401(k) Benefits - Outpatient Setting - 10 Paid Holidays

DEPARTMENT: SNF/Cont CareSCHEDULE: Full time regular, 40 hours/week, Day shift, Monday-Friday including Saturday and Sunday. Requires travel between Medical Centers and assigned SNF´s within Service Areas.EDUCATION/LICENSE/CERTIFICATION: BSN or BA in health care related field preferred. Graduate of accredited school of nursing. Current California RN license. PHN preferred. Current CA Drivers License required. Current BLS certificate required.JOB SUMMARY: Conducts utilization review for in-house patients and those members at contracted facilities. Assists in the discharge planning process.QUALIFICATIONS: Previous experience in an inpatient setting (usually 2 years). Previous experience utilization experience required (usually 1 year). Clinical expert in area of review preferred. Demonstrated knowledge of diagnostic codes.PREFERRED QUALIFICATIONS: Conducts utilization review for in-house patients and those members at contracted facilities. Assists in the discharge Minimum 2 years´ experience within the past five years in an acute medical-surgical setting or skilled level required Minimum 2 years strong QA/UR experience preferred Experience working in chronic disease management and/or with older adult caseload Team leader experience or experience directing the work of others preferred. Excellent clinical assessment and management skills are essential Must demonstrate skills in verbal, written communication, and interpersonal skills. Demonstrated ability to work independently Demonstrated excellent attendance record required. Computer word processing knowledgeDUTIES: Conducts utilization review for in-house patients as well as those members who have admitted to contracted facilities. Conducts clinical reviews based on established treatment criteria. Reviews utilization patterns, identifies trends and problems areas for special studies. Assists other healthcare providers in the discharge planning process and triaging on alternative unit of care. Assists in collecting and assimilating clinical data to enhance the quality of services. Generates quality improvement results. Collaborates with physicians on clinical reviews, keeps them appraised of Kaiser clinical criteria. Reports and investigates unusual occurrences and questions inappropriate decisions based on their professional expertise. Interviews patients/caregivers regarding care after hospitalization. Counsels on Medicare and health care plan coverage. Coordinates referrals to appropriate agencies/facilities.DEPARTMENT SPECIFIC DUTIES:1. Monitors admission of Kaiser patients to contracted skilled nursing facilities and assures that the nursing facility has received all required information and documentation for appropriate care of the patient.2. Facilitates provision of other Kaiser services required for the patient, including physician care, during the patient´s SNF stay and at discharge.3. Tracks patients´ stay in the facility, including services received, medical and functional status and readiness for discharge.4. Authorizes initial and extensions of SNF care in consultation with the SNF physician, based on skilled care criteria, and issues notices of non-coverage to patients/families as described by regulatory agencies.5. Under protocol, gives direction to SNF´s for clinical management of patient problems.6. Maintains SNF charts/CMS/Health Connect with accurate patient data and documents all patient contacts and interventions into CMS.7. Acts as shift supervisor for SNF office staff.Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, KaiserPermanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Consistently supports compliance and the Principles of Responsibility (KP´s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superiorPLEASE NOTE: - Kaiser Permanente is an AA/EEO employer

North Star Hospital

North Star is Alaska’s premier behavioral health provider that specialized in helping young people with life’s challenges. We recognize that childhood should be a time of joy, fulfillment, growth, and nurturing care. We also recognize that situations happen that are beyond young people’s control or ability to effectively handle. Our programs at North Star work with the family and the community to help facilitate optimal growth and nurturing throughout times of childhood adversity. Our goal is to help young people get on a track that leads to a life of youthfulness – the life that child and adolescents deserve. We are currently searching for Utilization Review Coordinator to join our established team. The UR Coordinator will be responsible for ensuring that financial benefits are maximized in the treatment and discharge planning for assigned cases through initial and continued stay reviews and obtaining prior authorization work for discharge services. They will also serve as an effective liaison between the business offices and treatment team, implementing the discharge plan and active pursuit of appeals. Requirements This position requires a Master’s degree in Psychology, Counseling, Social Work, or other related field. Prior experience in UR is preferred. This candidate should have a strong knowledge of psychiatric care service delivery systems and third party reimbursement, as well as an understanding of admission and discharge function. Familiarity with psychiatric terminology, diagnostic terms and treatment modalities is preferred as well as a knowledge of medical record keeping and consults. Strong verbal and written communication skills and the ability to effectively meet deadlines are a must.

Who Cares? We Do!. . . for our patients, our communities, and each other Allina Hospitals & Clinics!Located in Minnesota and western Wisconsin, we are a not-for-profit system of hospitals, clinics and other health care services, united in caring for our patients with unparalleled talent, knowledge and technology; caring for our communities through collaborative efforts to promote stewardship, compassion and wellness; and caring for each other in an environment that puts patients first and helps passionate people excel. This is what makes Allina unique. Won´t you join us?Allina Commons is the Minneapolis-based headquarters of Allina Hospitals & Clinics, a not-for-profit health care organization serving patients and communities. Approximately 1,600 corporate and administrative service employees work at offices within Midtown Exchange, site of the historic Sears retail complex at Chicago Avenue and E. Lake Street. This community landmark, adjacent to the campus of Allina´s Abbott Northwestern Hospital, is the second largest building in Minnesota and includes offices, an internationally themed public market and residential units.Responsibilities:Assess inpatient and observation admission according to admission criteria for all different hospital disciplines (Mental Health, Substance Abuse, Acute Care, Rehab, Observation, etc.) Assess clinical data from medical records to assure appropriateness of patient´s admission. Ensure proper authorization requirements are met with each admission. Monitor continued stay, identify potential issues, and communicate the results and opportunities to nurses, physicians, finance, case managers, and payers. Provide consultation to medical and nursing staff, health information management, payers, patients, and patients on potential issues with reimbursement of hospitalization. Evaluate potential denials or payment issues and initiate communication with physician and / or clinician to assure proper documentation for selected admission status. Assure proper physician order is in the record for the correct patient status. If the order is incorrect, facilitate discussion with the appropriate physician. Refers case to a review physician when the treatment request does not meet necessarily per guidelines, when guidelines are not available, or per customer account instructions. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the attending provider.Qualifications:RN - BSN preferred. 3-5 years of acute care experience preferred. Understanding/ knowledge of Interqual and Milliman and Roberson Admission criteria, preferred. Knowledge of medicare, medicaid, and other third party payer admission requirement. Knowledge of managed care concepts including utilization management, prior authorizations, and denial and appeal process.Pay, Benefits & Work Schedule:***Temporary position*** 32 hours per week Day and Evening shifts Every other weekendWe have a place for you at Allina Hospitals & Clinics. If you are interested in becoming part of our award winning team of professionals, please apply online today at www.allina.com/jobs and reference job opening id 416930. Allina is proud to offer highly competitive salaries and comprehensive benefits that include a 401(k)/403(b), tuition reimbursement, day care reimbursement accounts, banking services and much, much more. Check online for other opportunities throughout Allina!

The UMass Memorial Medical Center is the award-winning clinical partner to the University of Massachusetts Medical School and part of the largest non-profit health care system in Central and Western Massachusetts.

Position Summary:Demonstrates successful appeal and audit responses to third-party payers concerning hospital clinical and bill claim denials. Serves as an educational resource for staff and physicians to reduce or eliminate denials. Position Qualifications:Massachusetts licensure as registered nurse required. Knowledge of CPT and ICD-9-CM required. Thorough knowledge of HIPPA, Medicare and Medicaid compliance regulations.Third party payer and billing system knowledge preferred. Ability to effectively use specialized computer based systems for gathering, reporting, and analysis of clinical data. Excellent organizational and communications skills required.Preferred: Knowledge of CMS billing and compliance regulations in the acute care setting, third party payer process, and Utilization Management experience.Required: RN licensure, knowledge of CPT and ICD-9 coding, excellent communication and organizational skills.

Qualifications: Current California RN license. BSN or BA or BS degree in healthcare related field such as management, health services administration. At least three (3) to five (5) years experience in utilization management and discharge planning in an acute care setting to also include previous supervisory or management experience. Demonstrated knowledge of operations and healthcare management; JCAHO, Title XXII, Medicare, MediCal and other local, state and federal regulations. Knowledge of managed care operations. Demonstrated interpersonal, negotiation, and management skills. Good oral and written communication skills.Duties: Assists in developing and maintaining policies and procedures for the Service Area or Medical Center related to Utilization Management. Collaborates with the multi disciplinary team´s to plan and coordinate care across the continuum. Coordinates and manages members´ care with non KFH hospital facilities and providers. Identifies risk management and quality of care issues across the continuum. Surfaces issues and any suggestions to the appropriate multi disciplinary team members. Manages transportation program to ensure appropriate utilization of resources which meet Health Plan guidelines and patient needs. Assures compliance with Federal, State, JCAHO, NCQA, other regulatory agencies and internal standards and requirements.Provides direction to staff regarding utilization review, care coordination, discharge planning, and other services across the continuum of care. Assists in conducting statistical studies in utilization trends, patterns, and outcomes. Hires, trains coaches, disciplines professional and clerical support staff. Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente´s Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente´s policies and procedures.In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.Kaiser Permanente is an EEO/AA Employer.Notes: Schedule varies.

Specializing in you...serving San Diego´s inland North County communities for more than 50 years, PPH is a family of outstanding healthcare facilities that cover an area of more than 800-square miles.

Specializing in you...serving San Diegos inland North County communities for more than 50 years, PPH is a family of outstanding healthcare facilities that cover an area of more than 800-square miles. As the largest hospital district in Southern California, we are also one of the most diverse. From our state-of-the-art Cardiac Care and Rehabilitation Facilities and busy Trauma Center to Home Healthcare, we deliver a full spectrum of health services to meet the needs of every member in our community.We have an excellent opportunity for a Full-Time Defense Audit Denials RN who will be responsible for the clinical review of all charges on patient encounters in five primary areas of focus: 1) payer defense audits 2) pre-billing chart to charge reviews on high risk patient encounters for compliance and /or lost revenue 3) post billing chart to charge reviews as areas of risk are identified 4) clinical denials to mitigate the loss of revenue 5) refund requests to review for missing chargesResponsibilities include:Summarize reviews into clear and concise reports for management review.Reports to include recommendations for corrective action, which can include staff training and process improvement; creates and maintains database of reviews performed and reports trends to management at least monthly; serves as a resource to clinical areas to identify lost charge improvement opportunities.Possess analytical ability to design methods, collect and review data, formulate appropriate solutions and compile reports. This individual prioritizes work based on findings and risk; performs multiple tasks and modifies review approaches based on the organizations changing situations and needs, and follows through to achieve final resolution. Ability to effectively communicate, both written and verbal, with all levels of the organization. Work independently and as a cohesive team member seeking opportunities throughout PPH to improve effectiveness in charge capture and increased accuracy of clinical documentation. Responsible for coordinating and managing appeals for clinical denial of payment by medical record review with input from the physician advisor, attending physician, nurse case managers, and UR nurses. Serves as a liaison between patient financial services (PFS). Provides Case Management (CM)and Utilization Review (UR) for appeal-denial related issues. Generates formal letters of appeal to the insurance carrier. Responsible for collecting and maintaining data relating to appeals and outcomes.Explores opportunities for improvement in an effort to increase hospital reimbursement and decrease the rate of clinical denials.Maintains ongoing education and working knowledge of insurance regulations and claims audit. Maintains data spreadsheets with ability to prepare and present reports as requested. Maintains and utilizes excellent interpersonal, verbal and written skills effectively with ability to work independently to prioritize workload to meet appeal deadlines. Performs other duties as assigned. Follows PPH rules, policies, procedures, applicable laws, and standards.Carries out the mission, vision, values, and quality commitment of PPH.We promote a philosophy that encourages growth and satisfaction. We provide a work environment that is open and empowering, where you can experience a wide range of clinical, educational, and management opportunities. We also support a healthy balance between your personal and professional lives. We are located in an area that is enriched with a sense of belonging, where everyone pulls together in a common philosophy of life. Its an area that affords all who live here the luxury to pursue any interest or lifestyle they choose.RequirementsMinimum Education: As required by certification and/or licensurePreferred Education: Bachelors Degree in NursingMinimum Experience: 2 years hospital denials management, 4 years experience in an acute care facility and/or health care consulting; and Quality Assurance/Utilization ReviewPreferred Experience: 4 years hospital denials management, 5 years experience in an acute care facility and/or health care consulting; Quality Assurance/Utilization ReviewRequired License: Current CA RN License and Valid Drivers LicenseWe invite you to join us in our Mission to Heal, Comfort, and Promote Health in the Communities We Serve!

Provides utilization management/case management by coordinating resources, assuring appropriate use of community resources, support and service delivery through the components of case management/utilization management. Three (3) years nursing experience required with one (1) year of utilization review or case management experience preferred.A current unencumbered Oregon Registered Nurse License required.Experience and/or training in health care delivery systems and managed care required.Experience and/or training in insurance benefits including Medicare and Medicaid required.Experience and/or training in database management and statistics is preferred.Baccalaureate Degree in Nursing is preferred.