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On Call RN Remote Part-Time Weekends

Kern Family Health Care, Bakersfield, California, United States of America Req #1385
Friday, June 21, 2019
We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications.  A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization.  Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).

Kern Family Healthcare. The friendly face

 

We are looking for fun, intelligent, team oriented people who believe in our core values: Trust, Respect and Integrity.



PRIMARY PURPOSE:

 

Under the direction of the Kern Health Systems (KHS) Chief Medical Officer (CMO) or their designee(s) and the Administrative Director of Health Services, On Call RN, Remote will promote coordination and continuity of care and quality management in both the inpatient and ambulatory care settings through after hours support for Utilization Management (UM) administrative and clinical functions by the review of service requests  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 On Call RN, Remote manages the cases on an ad hoc basis during Saturday and Sunday on call rotations. Additional duties may include discharge planning and telephone triage functions.
 

CLASS CHARACTERISTICS:
 

The On Call RN, Remote, is responsible for assigned utilization case management functions for a Knox-Keene licensed health maintenance organization (HMO).  The On Call RN, Remote,  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 of care coordination. Incumbents are expected to possess an advanced knowledge of health care delivery systems and HMO regulatory requirements, including DMHC and CMS compliance. 

 

SUPERVISES:          None

 

MAJOR DUTIES & RESPONSIBILITIES:

  • On a 48 hour, every other weekend rotation, review and approve specialty and ancillary service referrals using established criteria for purposes of pre-authorization of payment.

  • Review and approval of hospital admissions and length of stay, and outpatient procedures for all care delivered to the KHS membership.

  • Coordinates discharge planning activities with facility discharge planners.

  • Document services rendered in the On Call log for tracking and trending purposes

  • Benefits interpretation to include coordination of care for medically necessary services that are not covered under the KHS Plan e.g. CCS, Mental Health, Long Term Care, State Waiver Programs.

  • Review of patient medical records for purpose of evaluation discharge planning needs and assessment of appropriateness of hospital stay.

  • Provide written and verbal communication with contract providers and internal KHS staff to promote timely coordination of care and dissemination of KHS policies and procedures.

  • Maintain and update information on contract providers, facilities and services in the KHS provider network.

  • Collaboration with the KHS Member Services Department and the Provider Relations Department regarding quality of care and other grievance issues in order to facilitate timely problem resolution.

  • Communication and collaboration with the KHS CMO or their designee(s) on denials for pre-authorization for specialty/facility services and other case management issues.

  • Serve as a consultant to contract providers to promote appropriate and timely case management to KHS members.

  • Participate in Utilization Management and Quality Improvement data and statistical gathering, collation, and reporting.

  • Perform other duties as assigned.

REQUIREMENTS:

 

CORE COMPENTENCIES / KNOWLEDGE & SKILL REQUIREMENTS

  • Demonstrated knowledge of and skills in protocols for utilization management, discharge planning and/or case management;

  • Strong knowledge of acute care nursing principles, methods and commonly used procedures;

  • Strong knowledge of common patient disease processes and usual methods for treating them;

  • Thorough knowledge of medical terminology, hospital routine and commonly used equipment;

  • Knowledge of acute hospital organization and interrelationships of various clinical and diagnostic services;

  • Proven ability to effectively evaluate medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans

  • Proven ability to assess and judge the clinical performance of physicians and other health professionals;

  • Knowledge of ICD9 and/or CPT coding;

  • Demonstrated thorough knowledge of health care delivery systems and HMO regulatory requirements, including DMHC and CMS compliance;

  • Ability to read, interpret and apply written regulations, guidelines and other materials;

  • Strong analytical, assessment and problem solving skills with intermediate negotiation skills;

  • Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of KHS;

  • Ability to use tact and diplomacy to diffuse emotional situations;

  • Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards;

  • Intermediate skills in Word and Excel with basic ability to enter data into and navigate through a database;

  • Demonstrated ability to commit to and facilitate an atmosphere of collaboration and team work;

  • Possess knowledge of payer source documentation requirements and governmental regulations affecting reimbursement;

  • Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to,  patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business;

  • Self-directed, with proven ability to work independently with minimum supervision;

  • Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis;

  • Ability to work autonomously with minimal oversight and remain compliant .with established processes and protocols

  • Strong attention to detail; work accurately and at a reasonable rate of speed;

  • Compliant with KHS policies and procedures; performs the job safely and with respect to others, to property, and to individual safety.

 

EDUCATION, EXPERIENCE & TRAINING REQUIRED:

  • 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 or UM Clinical Intake Coordinator RN with Kern Health Systems;

  • Bachelor’s Degree in Nursing, Health Administration or related healthcare field preferred.

     

OTHER REQUIREMENTS:

  • Registered Nurse with an active, current, unrestricted CA license;

  • Valid California Driver License; Up to 10% driving required (to home office for training and/or meetings);

  • Bilingual preferred.

     

     

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.

Other details

  • Pay Type Hourly
  • Travel Required Yes
  • Travel % 10
  • Telecommute % 0
  • Required Education Associate Degree
  • Kern Family Health Care, Bakersfield, California, United States of America