UM Specialist (LVN) - SNF - Sharp Extended Care - Days - FT
Company: SHARP HEALTHCARE
Location: San Diego
Posted on: April 24, 2024
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Job Description:
HoursShift Start Time:8 AMShift End Time:4:30 PMAdditional Shift
Information:8 hour shiftsWeekend Requirements:No WeekendsOn-Call
Required:NoHourly Pay Range (Minimum - Midpoint - Maximum):$33.946
- $43.802 - $53.657 -The stated pay scale reflects the range that
Sharp reasonably expects to pay for this position.--- The actual
pay rate and pay grade for this position will be dependent on a
variety of factors, including an applicant's years of experience,
unique skills and abilities, education, alignment with similar
internal candidates, marketplace factors, other requirements for
the position, and employer business practices. - -
What You Will Do
To provide comprehensive utilization management and coordination of
care for members who are confined to skilled nursing facilities
(SNF) in collaboration with designated SNF physician or Sharp
Community Medical Group primary care physician, as appropriate to
ensure cost effective quality service throughout the continuum of
care.
Required Qualifications
Preferred Qualifications
Essential Functions
Facilitates direct admissions to SNF from the Emergency Room,
Physician offices, or home coordinating with the SNF admission
liaison for authorization of level of care as appropriate.
Assists with transfers to SNF of Medical Group members from Out of
Network (OON) and /or Out of Area (OOA).
Reviews and updates SNF daily census log, adds new patients and
makes corrections when needed reconciling patients/facility
location, HP information and SNF benefits.
Reviews every patient under assigned workload one business day and
assigns an LOS based on MCG, prior level of function,
comorbidities, and discharge goals. Rounds and /or reviews with the
Sharp Extended Care (SEC) provider on site and/or
telephonically.
Keeps SEC Nurse Supervisor or SEC provider of any adverse
development, delay in discharge or services, readmissions to acute
or visit to the ER.
Attends and participates in SNF rounds, and/or patient care
conferences as appropriate.
Attends clinical in-services or required operational/clinical
training sessions.
Informs quality department of any quality issues.
Performs a comprehensive review of medical history, doctor's
orders, progress notes, therapy notes, vital signs sheet,
laboratory results, discharge planning notes and other pertinent
medical information to determine whether patient is meeting skilled
care criteria based on MCG Recovery Care Guidelines and Healthplan
SNF guidelines.
Performs data entry related to patient management activities using
the IDX computer system per departmental guidelines.
Complies with contracted health plan requirements for documentation
of concurrent SNF review and utilization management activities
performed in a manner consistent with Medical Groups' policies and
procedures.
Assists in obtaining medical information necessary for activities
related to Medical Groups' Quality and Appeals processes.
Authorizes appropriate care levels, i.e. sub-acute, short term SNF
or custodial. as well as services and supplies through patient's
medical group (or health plan, as applicable).
Provides authorization as needed for DME or other services for post
skilled nursing facility placement or home care.
Ensures compliance with all applicable regulatory and health plan
guidelines for issuance of notice letters i.e. Medicare notice of
non-coverage, Commercial notice of non-coverage or Exhaustion of
Benefit etc. Assures that letters are issued accurately and served
timely to members or responsible party.
Identifies services that are not medically necessary and/or not
covered benefits and accurately follows Health Plan and/or Medicare
Guidelines when issuing denials.
Ensures that all denials for medical necessity are issued under the
direction of the appropriate Medical Group Physician
Representative.
Identifies patients going into custodial level of care and
appropriately recording changes in level of care in IDX per Medical
Group guidelines.
Collaborates with Medical Group Appeals on members with SNF
services under appeals process.
Reviews SNF claims for medical necessity and appropriateness when
any information on the claim is disputed and claims department is
requesting verification.
Works collaboratively with the Hospitalist Care Team and Care
Management staff to ensure smooth transitions through out the
continuum of care. Communicates with patient, their family, the
physician and the interdisciplinary team as appropriate regarding
insurance coverage, discharge planning support, and post discharge
care needs.
Performs discharge planning function based on specific SNF specific
protocols or promotes timely assessment of discharge planning needs
by the facility.
Facilitates timely referral to social work and/or patient financial
services for financial screening on patients requiring long term
custodial placement.
Accurately documents patient's clinical condition and maintains
detailed, accurate, and timely data files on each patient.
Assigns and documents level of care based on SHC contracts and/or
MCG Recovery Care Guidelines.
Communicates and collaborates with SNF physician and SNF team to
explore alternative care option if patient does not meet skilled
level of care.
Makes appropriate referral to Medical Groups' Care Management
programs.
Communicates with the appropriate Quality Management Department
regarding any quality of service or quality of care issues
encountered in the course of review. Collaborates with the Medical
Groups Pharmacy Benefits Administration regarding appropriate
post-discharge pharmaceutical needs or complex pharmacy-related
care management needs.
Knowledge, Skills, and Abilities
Sharp HealthCare is an equal opportunity/affirmative action
employer. All qualified applicants will receive consideration for
employment without regard to race, religion, color, national
origin, gender, gender identity, sexual orientation, age, status as
a protected veteran, among other things, or status as a qualified
individual with disability or any other protected class
California Licensed Vocational Nurse (LVN) - CA Board of Vocational
Nursing & Psychiatric Technicians; Other
Keywords: SHARP HEALTHCARE, National City , UM Specialist (LVN) - SNF - Sharp Extended Care - Days - FT, Other , San Diego, California
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