Description: Under the direction of the Kern Health Systems (KHS) Medical Director and Director of Health Service the U.M. Nurse RN will promote coordination and continuity of care and quality management in both the inpatient and ambulatory care settings by the review of referrals and authorization of payment for specialty care and ancillary services. The review will evaluate the appropriateness of care using established criteria and Plan benefit guidelines. Review will be conducted on a prospective, concurrent, and retrospective basis. The UM Nurse RN manages the required caseload on a monthly basis. Additional duties may include discharge planning and telephone triage functions.
The Nurse RN is responsible for assigned utilization case management functions for a Knox-Keene licensed health maintenance organization (HMO). The UM Nurse RN is required to demonstrate competency in the knowledge of and skills in protocols for utilization management, discharge planning and/or case management, including the most difficult aspects. This may involve functioning at a higher capacity of utilization review, such as routinely assisting in the training, mentoring and assignment review of lower-level UM Case Managers and Support Staff, as well as assisting management with varied assignments. Incumbents are expected to possess an advanced knowledge of health care delivery systems and HMO regulatory requirements, including DMHC and CMS compliance.
"2,000 SIGN ON BONUS"
Requirements: Minimum of two years (2) full-time experience or its equivalent as a nurse in an acute care hospital, at least one (1) of which was working within a medical/surgical ward or unit. Three (3) years of full-time, paid work experience equivalent to that gained as a UM Nurse RN with Kern Health Systems. Bachelor’s Degree in Nursing, Health Administration or related healthcare field preferred. Registered Nurse with an active, current, unrestricted license. Valid California Driver License; Up to 10% driving required. Bilingual preferred.
We have an excellent benefit package to include: health care, dental, life, 457b and 401a plan, and other supplemental benefits. As a condition of employment, a satisfactory drug test and background check are required. E.O.E.