Travel Nurse RN - Case Management
Sacramento, CA
Uniti Med
5x8 hrs, Days
Referral Bonus

Description: Required: -CA RN License -prior UM experience for insurance companies is a MUST!! -EPIC & InterQual exp *position is remote*
Conducts preauthorization, concurrent, and retrospective utilization management review using the departments accepted criteria for ambulatory, acute, and post-acute patients to confirm medical necessity is met and at the appropriate level of care. Coordinates the utilization management, resource management, discharge planning, post-acute care referrals and care facilitation. Strives to promote patient wellness, improved care outcomes, and efficient utilization of health services among a patient population with complex health needs. General Referral Management:• Provides inpatient and ambulatory referral review - manages prior authorizations and retrospective referrals as documented in Utilization Management (UM) Operations Policies and Procedures.• Process referrals based on application of criteria (such as Medicare, MCG, InterQual, health plan, Sutter Health, etc.). Collaborate with UM Medical Directors routinely regarding referrals and all cases not meeting criteria.• Ensure appropriate authorization and denial letters are issued. Work collaboratively with UM staff to handle daily work.• Document all referral activities thoroughly in computer system documentation area (i.e. EPIC, Midas). Facility-based UM:• Conducts preauthorization, concurrent, and retrospective review using accepted criteria (i.e. Medicare, MCG, InterQual, etc.) for acute hospitalized and post-acute patients to ensure medical necessity for inpatient days and appropriateness of level of care. During acute hospitalization and post acute facility stays, consults with facility care team to develop goals to enhance functional status, identify discharge planning needs and provide continuity of care using community resources.• For cases not meeting criteria, the case manager documents applicable guideline, rationale, and routes to the UM Medical Director for further review.• Issues & documents facility or regulatory letters as applicable (i.e. Authorizations, Notice of Medicare Non-Coverage, Detailed Explanation of Non-Coverage, Refusal to Transfer, Notice of Non-Coverage Termination of Services letters, etc.).• Works collaboratively with members of a patients care team (i.e. physician, nurses, rehab team, social worker, facility case managers, etc.). This includes active participation in interdisciplinary meetings in acute or post-acute settings.• Provide authorizations to contracted facilities in accordance with health plan contracts or facilitate obtaining letter of agreements as needed. • Facilitates repatriation of out-of-network patients and escalates as needed when there is a delay in repatriation. Case Management:• Identify and refer patients to Sutters Value Based Case Management team as appropriate (includes complex case management, transitions of care, disease or population case management, etc.).