| Company: | Health Texas Medical Group of San Antonio
San Antonio, TX |
| Job Location: |
San Antonio - Bexar County
|
| Employment Type: | Full Time |
| Department: | UM/CRU |
| Salary Range: | Competitive |
| Benefits: | excellent |
Description: |
Actively participates in assessment and coordination of the HMO patient’s care through discharge planning and oversight of the referral process. Interfaces directly with physician, members and other providers to enhance cooperation and understanding regarding managed care programs/benefits. Develops and implements utilization management protocol that compliment both cost effectiveness and quality. Tracks and trends major utilization management bench marks.
|
Duties: |
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties that are not reoccurring in nature may be assigned.
Performs concurrent hospital review to assess utilization of resources and assists with effective discharge planning coordination of services and follow up care. Follows Milliman Care Guidelines as resource tools to assure quality care.
Investigates patient care alternatives to provide cost effective, quality care individualized to the patients’ needs.
Develops accurate tracking mechanism of all approved /deferred services to enable projections of managed care performance and ensure appropriate quality patient care. Demonstrated sound knowledge of computer system through accurate entry and report utilization.
Provides consistent reporting to Patient Care Committee, Peer Review Committee and management concerning Utilization of hostile and referral sources. Assists in developing protocols for preventative care and major referral patterns.
Communicates authorization status of services to HMO’s as appropriate. Maintains effective communication with HMO’s Interfaces with HMO patient to keep them within the CareNet system and increase their understanding of the benefits. Provides direct education to HMO members via orientation programs, health fairs, etc.
Develops follow-up mechanisms for outstanding or unresolved requests to ensure that timely care is provided.
Nurtures effective working relations with physician and staff so they will cal on Managed Care staff as a resource and seek assistance with specific patients.
Active participation in Quality Improvement through such activities as occurrence reporting, special projects, grievance review, program evaluation, etc. Assist documenting departmental policies and procedures fro training and replication.
Actively support team concepts by answering phones as needed, offering assistance to team members, etc. Contributes to eh overall development of the department.
|
Qualifications: |
QUALIFI CATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirement listed on the Minimum Qualification Checklist are representative of the knowledge, skill and /or ability required.
EDUCATION and/or EXPERIENCE
Graduate of an accredited school of nursing, BSN preferred. Current TX licensure required. 5 years strong clinical background, with strong interpersonal and organization skills. Prior HMO/Managed Care experience preferred, or equivalent education and experience.
Candidate must be non-tobacco user. |
