PURPOSE

The Medical Management department is participant focused and strives to provide the best possible care for the participants through Utilization Review and Utilization Management services, Care Coordination and Population Health Management. The Medical Management department also assists participants in receiving care with specialists outside the service area when appropriate. The Department is designed to ensure the delivery of high quality, cost efficient healthcare for our participants and families through coordinating care, providing detailed discharge plans, advising participants of different programs available and providing face-to-face and telephonic education.

The purpose of this position is to ensure that the Fund’s philosophy of assisting patients to receive the best quality care in the appropriate setting is accomplished. Will work with participants in the acute hospital and lower level of care settings to help guide them through the continuum of care. Will assess, plan, implement, coordinate, monitor, and evaluate care options and services to meet our participants’ health care needs. In conjunction with the Transition Management Team, this position is responsible for ensuring that the discharge plan is achieved in a timely manner and effectively meets the patients’ needs.

ESSENTIAL JOB FUNCTIONS AND DUTIES

Work with participants of all ages in the acute hospital and lower level of care settings (LTAC, SNF, Rehab) to help them through the continuum of care

• In collaboration with the attending physician, responsible for continuous communication with all parties involved in the plan of care and decision-making to determine medical necessity and appropriateness of care for service utilization and expense


• Must follow all hospitals policies and procedures


• Daily driving within the Las Vegas Metropolitan area based upon assignment


• Daily redirect patients to Hospitalist physicians per guidelines


• Daily communication with attending physicians regarding treatment and discharge planning needs of the patient


• Participant in weekly status calls with the leadership team regarding respective patient care issues


• Provide the necessary interventions to assure effective and efficient discharge planning


• Research patient issues, barriers to care and report findings to management


• Coordinate and attend family conferences for difficult discharge planning i.e. hospice, long term care, non-compliance


• In conjunction with the hospital staff, coordinate hospital to hospital transfers


• Maintain comprehensive, accurate and up-to-date record of patient care


• Identify delays in care and send to physician reviewer for non-certification


• Identify quality issues and refer to the Quality Committee for review


• Serve as liaison between participant and physician to ensure timely completion of disability forms


• Delegate non-nursing functions to Transitional Care Coordinators


• Assist management in development of protocols and procedures as they relate to UM/CM


• Participate in the weekend on call rotation


• Perform benefit education to participants and providers


• Driving on Fund business and/or authorized to drive a Fund-owned or –leased vehicle


• Sets goals and achieve measurable results


• Contributes ideas to plans and achieving department goals


• Performs other duties as assigned within the scope of responsibilities and requirements of the job


• Performs Essential Job Functions and Duties with or without reasonable accommodation

ESSENTIAL QUALIFICATIONS

Years of Experience and Knowledge

• Minimum 3 years’ experience in a hospital environment or equivalent required


• Experience with Case Management and Managed Care preferredEducation, Licenses, and Certifications


• Associate's degree in Nursing required


• Preferred: Bachelor’s degree in Nursing


• Preferred: CCM certification


• Required: Valid, unrestricted state driver’s license


• Personal vehicle registration and insurance


• Unrestricted active RN License in the State of Nevada


• Willingness and ability to obtain a license in other States as may be required by the Fund

Skills and Abilities

• Microsoft Office skills (PowerPoint, Word, Outlook)


• Microsoft Excel skills


• Preferred fluency (speak and write) in Spanish


• Excellent written and verbal communication skills


• Excellent interpersonal skills – ability to express compassion and balance the emotions with business needs


• Strong analytical skills


• Communicate clinical information to non-clinical individuals


• Manage competing deadlines and multiple projects in a fast-paced environment


• Must be fully vaccinated against COVID19

***Remote work available after 6 months of employment. Daily visits to assigned hospitals will be required.

***Must be local to Las Vegas, NV