Reporting to the Manager, Care Coordination & Social Services, Social Services, this position will help promote resource and revenue outcomes through the assessment, plan development, and implementation of processes to manage insurance denials, maximizing reimbursement, decrease revenue loss and help facilitate compliance to regulatory requests regarding resource utilization.
1. Current licensure as a Registered Nurse in the State of California is required.
2. A degree from an accredited baccalaureate program is preferred.
3. Previous experience in at least two areas of clinical specialty, Utilization Review and Case Management, with effective written and oral communication skills, good evaluative, interpretive, collaboration, and problem solving skills is required.
4. The incumbent must have knowledge regarding hospital protocol and procedures, familiarity with community resources, outside professional agencies, state and federal regulations governing hospital and home care, as well as understanding of the financial
structure of health plan and delivery systems and utilization review criteria.
5. Competence in basic computer applications including Microsoft Word, Powerpoint and Excel is preferred.