Under general supervision, to review service requests for Valley Health Plan (VHP) members in accordance with regulations, established policy, and procedures; to identify and report quality of care issues; to perform concurrent inpatient admission review, including of hospital acquired conditions; to conduct root cause analyses; and to evaluate clinical care to determine quality outcomes; and to undertake other mandated coordination to ensure the provision of quality health care services for VHP members.
Sufficient education, training, and experience to demonstrate the possession and direct application of the following knowledge and abilities:
Training and Experience Note: The required knowledge and abilities are attained through possession of a Master’s degree in Nursing, Health Care Management, or a related field from an accredited college or university;
OR
Two (2) years of nursing experience in any patient care setting;
OR
One (1) year of experience in utilization management, case management, or equivalent in a managed care environment.
Possession of a Utilization or Case Management certification is highly desired.
Special Requirements-
Possess and maintain a valid California Registered Nurse License.
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Ability to travel to alternate locations in the course of work. If driving, possession of a valid California driver’s license prior to appointment and the ability to qualify for and maintain a County driver authorization.
Knowledge of:-
Federal and State health care laws, regulations, and standards relating to quality of care, and standards of practice for professional staff;
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Utilization, case management, and claims payment systems;
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Billing/reimbursement practices in the healthcare industry;
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Clinical nursing practice and levels of care and treatment;
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Cultures represented in the diverse population of Santa Clara County and how members of those cultures relate to the health care industry;
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Compliance and regulatory requirements of a health plan/managed care organization;
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Managed care guidelines, including, but not limited to, Milliman Care Guidelines, Centers for Medicare & Medicaid Services, and Medi-Cal.
Ability to:-
Communicate effectively in English, both orally and in writing;
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Assess, identify, evaluate, process, and implement changes as needed to improve medical outcomes;
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Maintain effective data collection, recordkeeping, and reporting systems;
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Evaluate and interpret data and statistics;
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Analyze problems and formulate and implement effective solutions;
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Work effectively with professional staff, subordinates, vendors, customers/patients, network providers, and others in a courteous and professional manner;
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Interpret and maintain knowledge of healthcare laws, regulations, standards, policy, and procedures;
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Think critically and evaluate needs based on standard practice guidelines;
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Evaluate trends, conduct root cause analyses, and suggest operational improvements;
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Work independently in setting priorities and making effective decisions.