Nurse Coordinator I - RN

Job description

Overview The incumbent utilizes clinical judgement in providing utilization management services. The focus is to provide high quality, cost-effective care which will enable patients to achieve maximum medical improvement while receiving care deemed medically necessary. Assists in determining appropriateness, quality and medical necessity of treatment plans using pre-established guidelines. This position may be assigned cases in long-term care and ancillary, DME or medical services. Responsibilities: - Conducts retrospective claims review, either in the aggregate or on an individual basis. Provides summaries of findings to the Team Manager UM. - Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC and/or CMS regulatory requirements and Partnership policies and procedures for each product line. - Recommends and coordinates interventions to facilitate high quality, cost-effective care, monitoring treatment, progress and outcomes of patients. - Documents and maintains patient-specific utilization management records in database and files. - Assists in the refinement/improvement of the HS programs. Participates in co...