Prospect Medical Holdings

The Case Manager, UR is responsible for overseeing the daily operations of the assigned caseload. Ensures Medical Necessity for patient admission and concurrent stay at the short-term acute hospital level of care are met, utilizing the facility approved non-MD reviewer guidelines. Communicates as appropriate to the payer. Refers all cases not meeting MN for second level review. Ensures a safe and timely discharge / transition to the next appropriate level of care. Ensures timely escalation of unresolved care coordination issues to the appropriate level/entity. Enters delays in service and avoidable days regarding exceeded payer LOS variances. Communicates denials and physician related utilization management practices to immediate supervisor same day as identified. Keeps facility administration and CM Manager / Director of Utilization Management aware of any daily operational / physician related issues. Works closely with the facility Physician Advisor and Corporate. Works collaboratively with health care team, patients and families, administration and members of the Medical Staff. Responsible for active participation in daily weekday intra disciplinary patient rounding.

$10,000 Sign-on Bonus

• Completes TAR for assigned Medi-Cal patient population/ obtains authorizations for managed care accounts and submits appeals for all denied cases. Maintains confidentiality of all information according to Hospital Policy and Procedure and legal and regulatory requirements.
• Reviews hospital admissions and continued stays in accordance with procedures, criteria, and standards approved by the medical staff. Identifies opportunities for improvement in the current processes and procedures. Escalates unresolved issues to direct supervisor of UM Facility Administrator per escalation process.
• Collaborates with Social Services, Clinical Team, patient and families to prepare patient’s discharge planning needs. Oversees appropriate DC documentation. Works with Social Service to perform a variety of miscellaneous services, such as arranging for discharge or post-hospital plans, placement of patients in skilled nursing facilities or board and care homes.

Southern Cali Hospital Culver City

Required Qualifications:

• Current Licensure as a Vocational Nurse or LPT in the State of California
• Two (2) years of experience in utilization review/management in a managed care or hospital setting.
• Knowledge of The Joint Commission and Title XXII regulations
• Knowledge of CMS, MCARE, MEDI-CAL and Managed Care Reimbursement.
• Knowledge in insurance authorization and verification
• Knowledge of Interqual and /or Milliman Care criteria
• Excellent written and verbal communication skills in English
• Computer/EMR Proficiency
• AHA Basic Life Support
• De-escalation certification upon hire; Upon recertification, SAMA Certification required
• Hospital Fire and Life Safety Card (Los Angeles City Employees only)

Preferred Qualifications:

• Three (3) years clinical experience in psychiatric hospital setting.
• Care Management Proficiency with Milliman Care Guidelines or Interqual

Pay Rate: Min - $38.25 l Max - $51.39

$10,000 Sign-on Bonus

Southern California Hospital at Culver City has been taking care of generations of Culver City and west LA residents. We are a full-service, acute care hospital with a 24/7 emergency department and nationally recognized patient safety. Now at 420 beds, SCH-CC is a general acute care hospital that utilizes many of the latest medical treatments and technologies. The hospital offers a wide range of inpatient and outpatient acute care services, including an orthopedic center, cardiovascular services, acute rehabilitation, sub-acute care, psychiatric care and chemical dependency programs. Additionally, SCH-CC operates a 24-hour emergency services center, which serves as a paramedic receiving station and is staffed by board-certified emergency physicians and nurse specialists.

Union Pay Info: https://www.pmh.com/schccunion-8hr/

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• 3828 Delmas Terrace, Culver City, CA, 90232, US
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