Location: Orange,CA, USA
Job DescriptionResponsible for coordination of daily inpatient services including assessments, treatment planning, monitoring, evaluation, documentation and discharge planning function in accordance with Prospect Medical Group policies, procedure and processes. Interacts with the Medical Directors and hospitalists on a daily basis to determine necessity of continued stay.ResponsibilitiesEffectively manage patients either telephonically or onsite during their hospitalization to ensure the appropriate level of care is provided for the patient's severity of illness. Utilizes the appropriate tests and diagnostics in the right facilities to facilitate the highest level of care in the most efficient manner. Communicates effectively with facility staff and hospitalist to gather clinical information through verbal and written communications, and provides timely and accurate responses to request information or provide authorization decisions.Interacts with hospitalists and patients daily to evaluate plan of care including discharge planning to determine that patients are receiving quality care and appropriate discharge disposition. Applies medical knowledge to authorize outpatient services as an alternative to hospitalization when appropriate. Arranges for transfer to in-network care when appropriate.Updates clinical information in the electronic medical management record system with treatment plan, objectives, results and next steps. Documents all information accurately.Initiates and continues direct communication with health care providers involved with the care of the member, including the IPA or Hospitals Group if applicable, to obtain complete and accurate information. Applies appropriate benefits.Anticipates and initiates discharge planning within twenty four hours (24 hours) of admission, completes post discharge call within 24 hours to identify barriers and prevent readmission. Identifies post discharge care needs and refer to the appropriate outpatient programs and/or providers.Utilizes current approved criteria along with clinical experience to make authorization decisions. Identifies cases not meeting criteria and provides clinical information and rationale to the Medical Director for review and determination.Actively participates in daily rounds with current and accurate clinical information. Prepared to discuss current treatment plans from the Hospitalists or Specialists, plan of care for discharge disposition and continuity of care.Effectively manage an average census of 20-25 patients at any given time.May be required to take After Hours On-Call pager coverage as assigned.Refers cases to the Medical Director as appropriate for denial of stay or review of potential observation status.May be responsible for timely development of denial letter language and member/provider notification regarding Medical Director's review determination.Identifies and refers cases appropriately for CCS, High Risk, Homebound, Hospice/Palliative, SNF, QI and Health Education, per policy, and documents referral in case file. Actively participates in internal quality and work flow enhancement projects, and other duties, as assigned. Identifies and reports departmental operational issues and resource needs to the appropriate identifies and reports under and over utilization of medical services, delays in service by provider or hospital or treatment and quality of care issues to the Medical Director.QualificationsMinimum Education: High School graduate required; Associate in Arts degree preferred.Minimum Experience: Three to five (3-5) years experience in a medical group or Health Plan setting with strong clinical skills and critical thinking. A t least 4 year's of concurrent review experience, preferably in a managed care setting. Experience with Microsoft Office Word (50 WPM).Req. Certification/Licensure: RN/LPN active unrestricted license required. Location-Based Pay Adjustment About UsWith approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.