RN Supervisor UM Prior Auth

Job Summary and Responsibilities As the Supervisor of Utilization Management (UM), under the guidance and supervision of the department Manager/Director, you will be responsible and accountable for coordination of services for Mercy Medical Group and Woodland Clinic Medical Group through an interdisciplinary process that provides a clinical and financial approach through the continuum of care. Promoting the quality and cost effectiveness of medical care by ensuring department staff are applying clinical acumen and the appropriate application of policies and guidelines to Managed Care prior authorization referral requests. Under general supervision, this position is responsible for coordinating the daily operations of the UM Pre-Authorization team in order to ensure requests are processed in a consistent and timely manner while observing regulatory guidelines. Responsible for day to day operations of the Pre-Authorization team to include timely response and appropriate evaluation of referral reviews, correct selection of criteria, accurate prep to the UM Physician reviewer when indicated, timely verbal and written documentation, and completion of the file. Ensures adequate staffing and assignments and adjusts workflow as needed to meet department goals. Manages team schedule including requests for time off and assurance of coverage during physician office hours. Organizes, structures, and chairs a minimum of one pre-authorization meeting per month, including other staff as appropriate. Motivates and coaches staff to include new-hire training, problem solving, and special projects. Assists manager with performance activities to include monitoring, coaching, educating, and providing feedback to team. Ensures UM Physicians are provided the relevant information needed to accurately review a referral. Fosters the relationship between the Pre- Authorization team and the Medical Director and Physician Reviewers. Tracks cost savings from activities over time to evaluate success of programs. Maintains or removes programs based on organization and department goals. Develops reports for leadership as required. ***This position is hybrid, work-from-home and in-clinic/office. ***This position will work rotating weekends. Job Requirements Minimum Qualifications: - 5+ years clinical experience. - 3+ years Utilization experience in health plan/UM operations, Acute or subacute utilization review. - Bachelors degree, or equivalent experience. - Clear and current CA Registered Nurse (RN) license. - Ability to demonstrate leadership and management skills. - Knowledge of all applicable federal and state regulations as well as accreditation standards. - Demonstrates a working knowledge of Utilization Management, UM review processes, and regulatory requirements. - Must have the ability to monitor, compile, report and analyze data/statistics. - Requires excellent human relations, interpersonal and oral/written communication skills. - Able to recognize and address the needs and concerns of customers. - Ability to interact with all levels of the organization as well as with external contacts. - Requires good knowledge and skills with Microsoft Office (ie: Word and Excel) and other computer information systems and applications. Preferred Qualifications: - 7 years UM experience with Charge/Lead/Supervisory/Management experience in Utilization Management department preferred. - Experience working with health plan auditors preferred. - Working knowledge of InterQual preferred. - Knowledgeable of NCQA and ICE preferred. Where You'll Work Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health – one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. Our 130+ clinics across the state of California deliver high-quality, patient-centric care with an emphasis on humankindness. Through affiliations with Dignity Health hospitals, along with our joint ventures and partnerships, we offer a robust, state-of-the-art health care delivery system in the communities we serve .We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled, qualities that are vital to maintaining excellence in care and service. One Community. One Mission. One California

RN

Manager/Supervisor

Full-time

2 months ago

RN Supervisor UM Prior Auth

Virginia Mason Franciscan Health Rancho Cordova, CA

Job Summary and Responsibilities As the Supervisor of Utilization Management (UM), under the guidance and supervision of the department Manager/Director, you will be responsible and accountable for coordination of services for Mercy Medical Group and Woodland Clinic Medical Group through an interdisciplinary process that provides a clinical and financial approach through the continuum of care. Promoting the quality and cost effectiveness of medical care by ensuring department staff are applying clinical acumen and the appropriate application of policies and guidelines to Managed Care prior authorization referral requests. Under general supervision, this position is responsible for coordinating the daily operations of the UM Pre-Authorization team in order to ensure requests are processed in a consistent and timely manner while observing regulatory guidelines. Responsible for day to day operations of the Pre-Authorization team to include timely response and appropriate evaluation of referral reviews, correct selection of criteria, accurate prep to the UM Physician reviewer when indicated, timely verbal and written documentation, and completion of the file. Ensures adequate staffing and assignments and adjusts workflow as needed to meet department goals. Manages team schedule including requests for time off and assurance of coverage during physician office hours. Organizes, structures, and chairs a minimum of one pre-authorization meeting per month, including other staff as appropriate. Motivates and coaches staff to include new-hire training, problem solving, and special projects. Assists manager with performance activities to include monitoring, coaching, educating, and providing feedback to team. Ensures UM Physicians are provided the relevant information needed to accurately review a referral. Fosters the relationship between the Pre- Authorization team and the Medical Director and Physician Reviewers. Tracks cost savings from activities over time to evaluate success of programs. Maintains or removes programs based on organization and department goals. Develops reports for leadership as required. ***This position is hybrid, work-from-home and in-clinic/office. ***This position will work rotating weekends. Job Requirements Minimum Qualifications: - 5+ years clinical experience. - 3+ years Utilization experience in health plan/UM operations, Acute or subacute utilization review. - Bachelors degree, or equivalent experience. - Clear and current CA Registered Nurse (RN) license. - Ability to demonstrate leadership and management skills. - Knowledge of all applicable federal and state regulations as well as accreditation standards. - Demonstrates a working knowledge of Utilization Management, UM review processes, and regulatory requirements. - Must have the ability to monitor, compile, report and analyze data/statistics. - Requires excellent human relations, interpersonal and oral/written communication skills. - Able to recognize and address the needs and concerns of customers. - Ability to interact with all levels of the organization as well as with external contacts. - Requires good knowledge and skills with Microsoft Office (ie: Word and Excel) and other computer information systems and applications. Preferred Qualifications: - 7 years UM experience with Charge/Lead/Supervisory/Management experience in Utilization Management department preferred. - Experience working with health plan auditors preferred. - Working knowledge of InterQual preferred. - Knowledgeable of NCQA and ICE preferred. Where You'll Work Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health – one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. Our 130+ clinics across the state of California deliver high-quality, patient-centric care with an emphasis on humankindness. Through affiliations with Dignity Health hospitals, along with our joint ventures and partnerships, we offer a robust, state-of-the-art health care delivery system in the communities we serve .We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled, qualities that are vital to maintaining excellence in care and service. One Community. One Mission. One California

RN Supervisor UM Prior Auth

Dignity Health Rancho Cordova, CA

Job Summary and Responsibilities As the Supervisor of Utilization Management (UM), under the guidance and supervision of the department Manager/Director, you will be responsible and accountable for coordination of services for Mercy Medical Group and Woodland Clinic Medical Group through an interdisciplinary process that provides a clinical and financial approach through the continuum of care. Promoting the quality and cost effectiveness of medical care by ensuring department staff are applying clinical acumen and the appropriate application of policies and guidelines to Managed Care prior authorization referral requests. Under general supervision, this position is responsible for coordinating the daily operations of the UM Pre-Authorization team in order to ensure requests are processed in a consistent and timely manner while observing regulatory guidelines. Responsible for day to day operations of the Pre-Authorization team to include timely response and appropriate evaluation of referral reviews, correct selection of criteria, accurate prep to the UM Physician reviewer when indicated, timely verbal and written documentation, and completion of the file. Ensures adequate staffing and assignments and adjusts workflow as needed to meet department goals. Manages team schedule including requests for time off and assurance of coverage during physician office hours. Organizes, structures, and chairs a minimum of one pre-authorization meeting per month, including other staff as appropriate. Motivates and coaches staff to include new-hire training, problem solving, and special projects. Assists manager with performance activities to include monitoring, coaching, educating, and providing feedback to team. Ensures UM Physicians are provided the relevant information needed to accurately review a referral. Fosters the relationship between the Pre- Authorization team and the Medical Director and Physician Reviewers. Tracks cost savings from activities over time to evaluate success of programs. Maintains or removes programs based on organization and department goals. Develops reports for leadership as required. ***This position is hybrid, work-from-home and in-clinic/office. ***This position will work rotating weekends. Job Requirements Minimum Qualifications: - 5+ years clinical experience. - 3+ years Utilization experience in health plan/UM operations, Acute or subacute utilization review. - Bachelors degree, or equivalent experience. - Clear and current CA Registered Nurse (RN) license. - Ability to demonstrate leadership and management skills. - Knowledge of all applicable federal and state regulations as well as accreditation standards. - Demonstrates a working knowledge of Utilization Management, UM review processes, and regulatory requirements. - Must have the ability to monitor, compile, report and analyze data/statistics. - Requires excellent human relations, interpersonal and oral/written communication skills. - Able to recognize and address the needs and concerns of customers. - Ability to interact with all levels of the organization as well as with external contacts. - Requires good knowledge and skills with Microsoft Office (ie: Word and Excel) and other computer information systems and applications. Preferred Qualifications: - 7 years UM experience with Charge/Lead/Supervisory/Management experience in Utilization Management department preferred. - Experience working with health plan auditors preferred. - Working knowledge of InterQual preferred. - Knowledgeable of NCQA and ICE preferred. Where You'll Work Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health – one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. Our 130+ clinics across the state of California deliver high-quality, patient-centric care with an emphasis on humankindness. Through affiliations with Dignity Health hospitals, along with our joint ventures and partnerships, we offer a robust, state-of-the-art health care delivery system in the communities we serve .We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled, qualities that are vital to maintaining excellence in care and service. One Community. One Mission. One California

Home Health Field Registered Nurse (RN)

21st Century Home Health Services Antelope, CA

At 21st Century Home Health Services (21HHS) , we treat every patient with the same empathy, compassion, and understanding we would show our own family. With more than 600 employees, we are the largest home health agency in San Francisco and the fastest-growing in the Bay Area. Today, we care for more than 4,000 patients across San Francisco, San Mateo, Santa Clara, Santa Cruz, Alameda, Contra Costa, Solano, Napa, Yolo, Placer, El Dorado, and Sacramento counties—and we are actively expanding into Marin and Sonoma counties. Our clinicians are dedicated not only to the patients they serve, but also to one another. The results speak for themselves: hospital readmission rates at 21HHS consistently remain under 10%, compared to an industry average of over 15%. We’ve also set a new benchmark for employee satisfaction in home health. Recognized as a 2024 Top Workplace, 21HHS fosters an environment of support, growth, and recognition through open communication and professional development opportunities. Key achievements include: San Francisco Chronicle Top Workplaces in the Bay Area : Ranked 3rd among all medium-sized companies and 1st among home health agencies. National Recognition : Ranked 12th among medium-sized healthcare companies nationwide and 1st among home health agencies. Patient and employee feedback on Yelp, Google, Glassdoor, and Indeed further validates our commitment to quality care and workplace excellence. By prioritizing engagement and satisfaction, 21HHS attracts top clinical talent and delivers outstanding outcomes, cementing our place as a leader in home health. Please note: All opportunities at 21HHS require being in the field visiting patients in their homes. This entry-level Field Registered Nurse position is designed to develop fundamental nursing skills within a home health setting while gaining an understanding of the company's operational goals and efficiencies. It serves as a foundational role for registered nurses aspiring to advance into case management. This position works under an Case Manager Registered Nurse position. Coverage Area: Antelope, Citrus Heights, North Highlands area \n DUTIES AND RESPONSIBILITIES Providing hands-on patient care including, but not limited to (must be within RN license scope): PICC lines, Wound Vacs & Care ,Kangaroo & feeding Pumps, Management of NG, G, and J tubes, Staple & suture removal ,Drains such as, JP, Biliary, Nephrostomy, ,Foley/suprapubic catheters (insertion, removal, and troubleshooting), PleurX drainage system ,Trach care, Blood draws, Ostomy management ,SQ and IM injections, IV antibiotic/TPN administration and Compression wraps. Provides direct patient care as defined in the state Nurse Practice Act Implements a plan of care initiated and directed by the Case Management Registered Nurse Provides accurate and timely documentation within 24-48 hours consistent with the plan of care Assesses and provides patient and family/caregiver education and information pertinent to diagnosis and plan of care Assists the registered nurse in performing skilled needs procedures and duties, which include preparing equipment and materials for treatments and assisting the patient in learning appropriate self-care techniques Participates in coordination of home health services, appropriately reporting the identified needs for other disciplines (HHA, OT, PT, MSW, ST) to the Case Management RN or other disciplines Uses equipment and supplies effectively and efficiently Participates in personal and professional growth and development Performs other duties as assigned by the Case Management Registered Nurse Retrieves communication on assigned patients. Uses information received as a basis for establishing priorities of care Gives a timely and pertinent report to the Case Manager Records pertinent and concise information that will reflect the patients' needs, problems, capabilities and limitations, as well as the patients' response to nursing interventions Entries will accurately record any incident that has a bearing on the patient. Reports pertinent information timely to the Case Management Registered Nurse and to Provider Attends weekly Case Conferences as required to coordinate and communicate information regarding patient care and treatment Ensures patient privacy in maintaining medical records and when providing care. Maintains professionalism and seeks opportunities to enhance knowledge of clinical skills Maintains productivity standards as directed by the Case Management Registered Nurse . Completes and reviews Start of Care assessments, documentation, and plans of care with Case Manager, as needed. Participates in on-call duties as required by weekend rotation Job Specifications One (1) year of recent nursing (RN, LVN) experience required One year of home health care experience is preferred. Experience with high acuity patients is a plus Experience working with an interdisciplinary team is highly desired Graduate of an accredited school of nursing (Bachelor's degree) Current CA Registered Nurse License (RN) Current Basic Life Support (BLS) Card Valid CA Drivers License with acceptable driving record All license and certifications must be current at time of hire and sustained throughout employment Self- directed, Critical Thinker, Outstanding interpersonal skills, Organized, Computer literacy. Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist. Must maintain current with annual compliance training and certifications \n $130,000 - $160,000 a year Estimated Wage Range for Home Health Registered Nurse (RN): $130,000 - $160,000. Starting pay is based on relevant experience above the minimum requirements. Compensation for this position follows a pay-per-visit model, with the wage provided as an estimate. 21st Century offers comprehensive health benefits and a 401k plan with up to a 4% match. \n 21st Century is an equal opportunity employer, committed to fostering a diverse and inclusive workplace. We strictly prohibit discrimination or harassment of any kind, including but not limited to race, color, sex, religion, sexual orientation, gender identity, national origin, disability, genetic information, pregnancy, or any other characteristic protected under federal, state, or local law.

Registered Nurse (RN)

LHC Group Antelope, CA

Why Suncrest At Brighton/Suncrest Hospice our goal is to change the expectation of hospice care in your area by providing exceptional care and service to our patients. This is achieved by allocating the resources to increase our staff to patient ratios, thereby increasing clinical visits while lowering clinician caseloads. We are proud to be a Community Health Accreditation Partner (CHAP) certified hospice. If you have a commitment to providing the highest quality of care to patients and their families, we would like to hear from you! Benefits Pay Range$49.00-$58.00 Actual Work/Life Balance Competitive Pay Benefits Package including Medical, Dental, and Vision insurance Paid Time Off 401k plan with employer match and 100% vesting after 90 days of employment A culture with an emphasis on appreciating and valuing the team member The opportunity to be part of a rapidly growing national company, with possible position upgrades Details The Registered Nurse (RN) will be responsible for providing care and services for a group of patients, visiting patients where they reside, which could include private homes, Skilled Nursing Facilities, and assisted living facilities. This position is a contributing member of the interdisciplinary team, providing expertise regarding psych-social assessments, interventions, and knowledge of community sources. The Registered Nurse (RN) will work in either a Case Management, Admissions, or Resource role. Qualifications Current Registered Nurse (RN) licensure (in good standing) in the state(s) of practice Works well within a team environment to collaborate daily with nurses, social workers, chaplains, volunteers, and CNA leadership. Work closely with patients on a 1-1 level but get strong support from a patient care team. Can work independently and on your own from a day-to-day basis with activities which include: phone, email and written communication, meetings with a variety of healthcare professionals, and an understanding of hospice rules and regulations. Time management skills to manage visits, documentation, meetings (i.e.: to scheduled visits, attend required meetings, respond to urgent needs by prioritizing and triaging multiple concerns) Ability to learn an electronic medical records system. Must be willing to drive with reliable transportation, valid driver’s license, and auto insurance, to be able to travel across the service area

Registered Nurse RN

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