Job description

Provides utilization management functions as a part of the Program for All Inclusive Care for the Elderly benefits management system. This includes providing utilization review and management for all acute, post-acute, and outpatient services as well as performing the identification, analysis and resolution of resource utilization outliers consistent with established protocols, policies and procedures. Serves as a liaison between network providers and the CV PACE clinical and Interdisciplinary Teams (IDT) related to participant assessment, care planning, and care coordination to assure participants progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. Works closely with finance and claims adjudication teams for the purposes of care management, data analysis and practice, and system performance.

Schedule is Monday – Friday, 8am – 5pm.

Compensation:

$103,833.60 - $120,203.20 annually.

Duties and Responsibilities

· Valid CA Driver’s License, acceptable driving record, and vehicle insurance.

· Detailed-oriented and organized.

· Excellent written and verbal communication skills with specific ability to maintain accurate records.

· Excellent customer service skills.

· Must have integrity, practice discretion and practice objective problem solving.

· Ability to collect, organize, manage and report on large volumes of meaningful data for decision making while using spreadsheets or other data processing software.

· Knowledge of basic statistical principles.

· Skilled in establishing and maintaining effective working relationships with participants, coworkers, medical staff, and the public.

· Skilled in identifying and recommending problem resolution.

· Knowledge of safety and infection control requirements for healthcare facilities.

· Demonstrated experience in quality assurance and performance improvement activities.

· Proficient in Microsoft Office applications; advanced Microsoft Excel experience required.

· Knowledge of State and Federal healthcare regulations.

· Only act within the scope of authority to practice.

· Meet a standardized set of competencies for the specific position description established by Central Valley PACE and approved by CMS before working independently.

Physical Demands

· Requires standing, walking, occasional pushing, pulling, and lifting.

· Ability to lift up to 30 pounds. Moving or lifting greater than 30 pounds should be done with assistance as appropriate.

· Requires manual and finger dexterity and eye-hand coordination.

Work Environment

· Exposure to biohazards, including infectious material and waste and any other conditions common in a health care environment.

· Subject to unpleasant odors

· The noise level is usually quiet to moderate, but may at times be noisy and crowded.

Education/Experience Requirements

Minimum Qualifications:

· Valid CA Driver’s License, acceptable driving record, and vehicle insurance.

· Detailed-oriented and organized.

· Excellent written and verbal communication skills with specific ability to maintain accurate records.

· Excellent customer service skills.

· Must have integrity, practice discretion and practice objective problem solving.

· Ability to collect, organize, manage and report on large volumes of meaningful data for decision making while using spreadsheets or other data processing software.

· Knowledge of basic statistical principles.

· Skilled in establishing and maintaining effective working relationships with participants, coworkers, medical staff, and the public.

· Skilled in identifying and recommending problem resolution.

· Knowledge of safety and infection control requirements for healthcare facilities.

· Demonstrated experience in quality assurance and performance improvement activities.

· Proficient in Microsoft Office applications; advanced Microsoft Excel experience required.

· Knowledge of State and Federal healthcare regulations.

· Only act within the scope of authority to practice.

· Meet a standardized set of competencies for the specific position description established by Central Valley PACE and approved by CMS before working independently.

Education/Experience:

· Graduate of an accredited school of professional nursing.

· Current unencumbered CA Registered Nurse (RN) License.

· Current BLS CPR Card certified by American Heart Association.

· Practiced nursing within the last three (3) years.

· Minimum one (1) year experience working with the frail or elderly population.

· BSN highly preferred.

· Minimum of three (3) years of managed healthcare experience including one (1) or more years in at least one of the following areas: utilization management, case management, care transition and/or disease management required.

· Certified Case manager (CCM) or Certified Professional in Healthcare Management Certification (CPHM) preferred.

Job Type: Full-time

Pay: $103,833.60 - $120,203.20 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Referral program
• Vision insurance

Medical specialties:

• Geriatrics

Schedule:

• 8 hour shift
• Monday to Friday

Ability to commute/relocate:

• Modesto, CA 95355: Reliably commute or planning to relocate before starting work (Required)

Application Question(s):

• Do you have a minimum of three (3) years of managed healthcare experience including one (1) or more years in at least one of the following areas: utilization management, case management, care transition and/or disease management?

License/Certification:

• RN (Preferred)

Work Location: One location

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