As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
The Lead Utilization Management nurse works under the direction of the Supervisor and Manager. The Lead assists Supervisor and Manager with the following; Leads the Utilization Review staff; monitoring daily workloads and case assignments; develops and delivers initial and ongoing systems and process training, auditing, coaching, and oversight of the operations to ensure all contract requirements and business initiatives are completed successfully and timely. Lead will be responsible for a owning a small caseload
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
Determines and documents medical necessity based on Milliman criteria.
Meets or exceeds established CMDM productivity standards.
Leads the Utilization Review process of telephonic and electronic chart review of inpatient members.
Assist with the designs and implementation of orientation, ongoing training and new program implementation.
Assists in developing clinical and economic outcomes measurement.
Provides coverage for Utilization Management staff when necessary.
Ensures a positive workplace culture promoting Conifer workplace guidelines; confidentiality of patient information and HIPAA regulations
Participates in Medical Services and Utilization Review Team meetings we well as work groups.
Communicates and resolves issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Experience in Utilization Review.
Experience utilizing Milliman Criteria preferred
Strong critical thinking and problem solving skills.
Ability to network, advocate, communicate assertively with all customers.
Ability to establish and maintain effective working relationships as required by the duties of the position
Experience working with high volume and strict timeframes.
Excellent analytical, communication, training and leadership skills.
Exceptional organizational skills.
Ability to work in a fast paced environment.
Must work independently as well as part of a team.
Must have experience working with a Medical Management platform systems including but not limited to; MS Word, Excel, and Outlook
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience preferred to perform the job.
Minimum Education: LVN or RN
Preferred Education: BA or BS in Nursing
Minimum Experience: 3 to 5 years of acute care experience
2 Years Health Plan Utilization Review or equivalent
Preferred Experience: 5 years Health Plan Utilization Review and 5 years Acute Care
Experience with 1 year ICU / ER
Include minimum certification required to perform the job.
Licensure must be current and unrestricted in the appropriate jurisdiction
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Must be able to work in sitting position, use computer and answer telephone
Ability to travel
Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Office Work Environment
Approximately 5% travel may be required
Primary Location: Westminster, California
Facility: Conifer Value Based Care
Job Type: Full-time
Shift Type: Days
If Other Shift, Specify: Mon-Fri
Shift Begin: 8:00 AMShift End: 5:00 PM
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Tenet Healthcare Corporation (NYSE: THC) is a diversified healthcare services company headquartered in Dallas with 112,000 employees. Through an expansive care network that includes United Surgical Partners International, we operate 65 hospitals and approximately 510 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, urgent care and imaging centers and other care sites and clinics. We also operate Conifer Health Solutions, which provides revenue cycle management and value-based care services to hospitals, health systems, physician practices, employers and other clients. Across the Tenet enterprise, we are united by our mission to deliver quality, compassionate care in the communities we serve.