Physician / Pediatrics / California / Locum or Permanent / RN, Utilization Management, Pediatrics - Irvine, CA Job - OptumCare

Monarch HealthCare is one of the largest associations of physicians and health care professionals in Orange County and Long Beach. Our network gives you lots of access to specialists, hospitals, skilled nursing, urgent care and more so you have the perfect fit for good health. Monarch is part of OptumCare, a care delivery organization that improves patient health and helps make health care work better.
The Utilization Management RN is responsible for the facilitation of the inpatient Utilization Management process including in - network, out of network, case management and discharge planning as well as assisting the Associate Director of Inpatient Management with UM / QM functions as necessary. Acts as a facility liaison to promote cooperation and efficiency between the IPA and the facility. This is an office based position, located in Irvine, CA that requires some travel (up to 30%) in the Orange County area.

There is a one time sign on bonus of $5,000 for this position!
Primary Responsibilities:

• Directly performs concurrent review
• Accurately identifies and documents level of care
• Coordinates, facilitates and documents comprehensive discharge planning
• Coordinates in - network services for out of network discharges
• Ensures the appropriate utilization of in network, capitated and contracted specialists, providers, facilities, and vendors according to region and risk
• Attends daily inpatient readmission review rounds and presents cases to medical director(s), Case managers and post acute services
• Facilitates out of network transfers to In - Network facilities
• Works collaboratively with internal and hospital contract staff :
  • Initiates letter of agreement for OON services in a timely manner
  • Provides input for potential contracts
  • Identifies and communicates high dollar / high risk cases
  • Oversees the utilization of contracted facilities and reports OON utilization
• Develops and maintains relationships with both network and Out of Network hospital UM and ER staff
• Works directly with Monarch Hospitalists to develop and implements inpatient processes including, but not limited to:
  • Identification of patients and referral to specialty clinics such as Comprehensive Care (high - risk) Clinic, Anti - coagulation and / or Diabetic Clinic
  • Facilitates and ensures timely communication between PCP and Hospitalists
  • Provides direct Case Management activities if necessary
  • Identifies readmit for CM coordinations
  • Identifies Healthy Families and Medi - Cal members for CCS referral and facilitates those referrals
  • Identifies and coordinates high dollar / high risk patients to case management
• Participates in UMC / QIC, PCP, Provider Office Meetings, health plan JOMs, and hospital JOCs as assigned
• Participates in inpatient UM / QM projects and completes in a thorough and timely manner

Youll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.