PPO Nurse Case Manager (RN) ( Full Time / Days )

To see a list of all Facey locations click here .

Providence is calling a PPO Registered Nurse Case Manager to our Facey Mission Hills location in Mission Hills, CA.

In this position you will:

Works under the direction of the Director

of Case Management with the PHSCA Medical Group providers and patients to

support and expedite urgently and routine services needing Health Plan prior

authorization or disposition to the most efficient network facility taking

preference for PHSCA facilities and providers .Assures submission of all prior

auths to payors contains appropriate clinical information in order for

plan/payer to review and make decision in a timely manner. Is a resource to the Payor/Health plan PPO ambulatory

nurses ensuring that appropriate clinical information and other needs are met

to expedite care. Understands the proper escalation of circumstances resulting

in barriers to care for our PHSCA patients. Ensures that cases where avoidable

delays are encountered are appropriately evaluated by the CM Director and where

necessary, the MG UM Medical Director. Works with the CM Director to understand

denial accuracy, denial timeliness, personal productivity, completion of

documentation to support decision in IDX including guidelines and references

cited. Works with Health Plan PPO Ambulatory Nurse Case Managers to develop and

maintain constructive working relationships with providers, health plans and

regulatory agencies. Works with staff to treat each other with respect and

professionalism as defined in our guiding Mission and Values.

Required qualifications for these positions:

RN graduate of an accredited

school of nursing, three to five years' experience preferred in a managed care

setting/utilization review/discharge planning/case management of which two

years is in hospital or ambulatory case management. Current California RN

license American Heart Association BLS for Health Care Providers required. Must possess excellent customer service and communication skills. Must be organized

and a selfstarter. Must have extensive knowledge of health plan requirements

and benefits as applied to the utilization and case management process and

clinical decision making. Must have working understanding of MS Outlook, Word

and Excel and be capable of being trained in referral processing software. Needs to be able to access and apply

all appropriate clinical guidelines

approved by Health Plan, Medicare MediCal or other payor resource to patient cases requiring prior authorizations . Needs to be aware of Health Plan criteria regarding

timeliness of referrals, denial rationale and denial language. Must

possess strong oral and written communication skills, problem solving and

analytical skills as related to Utilization Management.

Preferred qualifications for these positions:

Bachelor's degree

Three to five years experience in a managed care setting/utilization review/discharge planning/case management.

About the organization you will serve:

Facey is a Medical Group with offices in the San Fernando, Santa Clarita, Simi and San Gabriel Valleys. We are known as a multi specialty medical group, meaning we employ over 180 healthcare providers offering a broad range of specialties including primary care, OB/GYN and medical and surgical specialties. Facey operates two Urgent Care Centers (Santa Clarita & Mission Hills) that offer comprehensive physician services, lab and radiology seven days a week.

We have affiliations with several hospitals in our service areas including Providence Holy Cross Medical Center, Providence St. Joseph Medical Center, Henry Mayo Newhall Medical Center, Northridge Medical Center, Simi Valley Medical Center and San Gabriel Medical Center. We are physicians who treat members of various insurance plans. Facey contracts with most of the major health insurance plans. We see HMO, PPO, Medicare, MediCal and cash pay patients. For those who are Medicare eligible, Facey not only takes Medicare but we contract with many of the Medicare Advantage Prescription Drug Plans (MAPD -- HMO) as well as Medicare Supplement or MediGap PlansHigh School

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Providence Health & Services is the third largest not-for-profit health system in the United States. Providence employs more than 76,000 caregivers (employees) across a five-state area; AK, WA, MT, OR, and CA. Our facilities include 34

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