Medical Management Specialist, RN (SCAN Temp, Part-time)

**Average of 20-24 hours per week, worked over 3 days**

Medical Management Specialist, LVN/RN

About SCAN

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 270,000 members in California, Arizona, and Nevada. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.

The Job

The Medical Management Specialist-RN promotes and supports the quality, medical necessity and cost effectiveness of care and services based on State and Federal regulatory guidelines and Medical Policy. Using established clinical criteria and working under the auspices of the Clinical Supervisor, the Medical Management Specialist-RN is responsible for supporting the utilization management processes related to coverage decision, managing requests for items and/or services. Conducts pre-service and concurrent review following established guidelines in collaboration with Medical Director as secondary reviewer. Applies case management principles and practices to ensure complex medical needs, care and service are coordinated.

You Will

Ensure necessary inpatient and outpatient care and other services are rendered to SCAN members at the right time, at the right level of care and at the right location, adhering to all Medical Management policies and procedures. Issues determinations within required regulatory timeframes.

Collect all relevant information and apply nationally recognized, evidenced-based criteria and guidelines, including federal and state regulations and Medical Policy, to ensure necessary inpatient and outpatient items and services are provided with optimum outcomes and cost effectiveness, and according to DOFR and member eligibility.

Escalate requests to Medical Director following established guidelines, including secondary review for requests that do not meet criteria.

Manage complex medical cases by applying the essential activities of case management and utilization management including assessment, planning, implementation, coordination, advocating, monitoring, and evaluation. Prepare and deliver case presentations, participate in case rounds and interdisciplinary team meetings (IDT), and incorporate recommendations into member's care plan.

Assist members who require urgent and emergent medical and behavioral health services while outside the network or the SCAN service area, by working directly with members, caregivers, and providers to ensure the provision of quality, coordinated care. Authorize care and services needed for stabilization, and when appropriate, works to transition members and services back into the SCAN provider network.

Facilitate safe and effective discharges from inpatient settings by communicating member needs and issues identified during the course of inpatient treatment to other members of the care team, including but not limited to Facility CM, SCAN Care Management staff, medical group case managers, and Primary Care Physicians (PCPs).

Make referrals to other clinical programs per established criteria.

Address urgent member quality or access to care issues via the Quality of Care (QOC) process.

Escalate barriers to work processes to the attention of the supervisor/manager.

Maintain documentation and data entry requirements adhering to all Medical Management policies and procedures.

Maintain telephone standards by answering and returning calls and correspondence adhering to all Medical Management policies and procedures.

Build effective professional relationships with providers and other internal and external partners by using excellent verbal and written communication skills, developing trust, meeting timelines, respecting cultural differences, using active listening skills, and maintaining confidentiality.

Maintain the member's right to privacy and protect SCAN operations by keeping information confidential.

Maintain professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, participating in professional societies.

Retro clinical review of inpatient admissions, completion of case including Medical Director reviews as appropriate, and effectuating decisions in authorization and initiation of denial notifications according to regulatory requirements

Must be able to complete and close minimum of 20 cases per week.

Float to Prior Authorization as required by business.

Other duties as assigned.

Your Qualifications

• Graduation from an accredited school of Nursing.
• Current and active California Registered Nurse license required.
• Certified Professional of Utilization Management (CPUM or CPUR) or other Medical Case Management certification is preferred, or willing to attain such certification with 2 years.
• 3+ years of experience in medical-surgical nursing.
• 3+ years of Utilization Management/Prior Authorization experience in a Managed Care medical group, IPA, or managed care setting.
• Knowledge of (California) managed care industry, Medicare/MediCal required.
• Knowledge of Federal and State healthcare mandates and regulations.
• Health plan and vendor contracting knowledge.
• Proficient in Microsoft Word, Excel, Outlook, and PowerPoint, required.
• Strong analytic and problem-solving skills, required.
• Strong verbal and written communication skills, required.
• Ability to multitask and work closely with department RNs.
• Ability to work well in a fast-paced and dynamic environment.
• ICD-9, HCPCS and CPT coding knowledge.

What's in it for you?

• Base salary range: $45-52 per hour
• Remote Work Mode
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

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