Case Manager with Post Service and Medi-Cal experience Job in Woodland Hills, California US
Case Manager with Post Service and Medi-Cal experience
Kelly Healthcare Resources Kelly Healthcare Resources (KHR) is a specialty service of Kelly Services, Inc., a leader in providing workforce solutions. Launched in 1999, KHR services all levels of healthcare specialists and professionals in the following disciplines: medical laboratory, medical device, pharmacy and pharmacology, dental, nursing, allied health, behavioral health, healthcare billing/coding, utilization, case management, occupational health, special education, and physical therapy. Visit www.kellyhealthcare.com . Current Needs: Currently seeking an experienced RN Care Manager in San Fernando Valley . The work schedule for this is from Monday to Friday, between 8:00am-5:00pm. This is a long term assignment with a possibility of temp to hire. JOB SUMMARY: The Care Manager / Post-Service Review performs advanced and complicated case review and first level determination approvals for inpatient, outpatient and ancillary service requests, medical necessity appeals or claim review requests including high dollar claims after the delivery of services. Case reviews include determination of medical appropriateness and medical necessity requiring considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of departmental procedures, clinical guidelines and coding conventions. Acts as a liaison between medical management network management, claims, member services and other departments to resolve retrospective review issues. ESSENTIAL DUTIES AND RESPONSIBILITIES: Conducts advanced and complicated clinical review for inpatient, outpatient and ancillary service requests, medical necessity appeals or claims review requests including high dollar claims after the delivery of services. Case reviews include determination of medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines, benefit plans, product configuration and coding rules/convention. Makes first level approval determinations when appropriate. Conducts retrospective review of service requests, medical necessity appeals or claims submitted by contracted and non-contracted providers, delegated and non-delegated providers for all product lines. Certification/License: Active, valid unrestricted state of California Registered Nurse license required. UM/CM certification preferred. Experience: Minimum two years clinical experience. One - three years managed care experience preferred, including with an emphasis on claims review, medical billing or utilization/case management. Medi-Cal experience preferred. Health Plan experience preferred. Knowledge, Skills Abilities: Strong knowledge of NCQA, federal and state regulations/requirements. Demonstrated ability for assessment, evaluation and interpretation of medical information. Possesses an ability to understand and interpret complex contracts. Strong analytical and problem solving skills. Excellent verbal and written communications skills. Excellent case preparation and abstracting skills. Team player who builds effective working relationships. Ability to work independently. Experience using standardized clinical guidelines/criteria and with medical coding required. Strong organizational skills. Able to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and Project. Ability to effectively analyze, interpret, apply and communicate policies, procedures and regulations. Education: Required: Accredited nursing program Preferred: Bachelors Degree In addition to working with the world?s most recognized and trusted name in staffing, Kelly employees can participate in the following benefits: · Highly competitive pay · Access to eLearning Application Contact Info: For immediate consideration, click the ?Apply Now!? button, or refer a friend by clicking the ?E-mail this job? link provided. About Kelly Services Kelly Services, Inc. (NASDAQ: KELYA, KELYB ) is a leader in providing workforce solutions. Kelly ® offers a comprehensive array of outsourcing and consulting services as well as world-class staffing on a temporary, temporary-to-hire and direct-hire basis. Serving clients around the globe, Kelly provides employment to more than 530,000 employees annually. Revenue in 2010 was $5 billion. Visit www.kellyservices.com and connect with us on Facebook, LinkedIn, Twitter . Kelly Services?Celebrating 64 Years Kelly Services is an Equal Opportunity Employer.