Providence is calling a UM Regional Compliance RN ( Full Time / Days ) to our Facey Utilization Management location in Mission Hills, CA.
In this position you will:
Works closely with the UM Manager, the UM Regional Compliance Manager and Complex Case Management Manager to oversee the utilization compliance in the UM Departments of all Providence Health and Services California Medical Groups/Foundations.
Responsible for the day to day management of compliance and reporting requirements between Providence Medical Groups UM Departments per the Delegation Agreements with the contracted health plans.
Responsible for monitoring the accuracy of the documentation of member's letters (extensions, denials, carve out and authorizations), issuance and timely submission.
Able to identify risk and compliance issues, define and collaborate with UM Department leaders and providers and PHSCA CMO to implement Providence compliance with regulatory requirements.
Works with the Compliance Manager to prepare and coordinate health plan and other regulatory audits in UM, QM and Provider Contracting for all Medical Groups.
Maintenance of UM referral tools and letter templates in all formats, i.e. Aerial Care Coordination ( Cerecons) and Global Works Form Letters of GE Centricity MCA module.
Prepares training material for all UM staff in order to be compliant with all regulations.
Leads periodic scheduled meetings with the ambulatory nursing staff to ensure understanding of compliance issues, performs audit on nurse CM compliance and provides feedback to area UM Managers.
Works with the Compliance Manager to maintain UM Policy and Procedures.
Works closely with the Case Management Director, UM Director, Administrative Director of Health Services and Regional and local Medical Directors to ensure understanding and compliance.
Acts as a resource for all UM Directors, Managers and Supervisors on all compliance needs.
Required qualifications for this position include:
RN BSN graduate of an accredited school of nursing.
5 years experience in UM Ambulatory Case Management
Minimum 2 years supervisory experience required.
Demonstrates knowledge of operations.
Knowledge of Nurse Practice Act, NCQA, DMHC, CMS and DHS regulations.
Excellent writing skills and understanding of readabiity requirements for member referral letters and communication.
Experience in compliance audits.
Knowledge of HMO processes, benefits, ICD9/10, CPT Coding. Must possess excellent customer service and communication skills.
Must be able to discuss medical issues with Physicians.
Needs to be organized and a self starter.
About the organization you will serve:
Facey Medical Group is a multi-specialty medical group with over 160 physicians providing care to the growing population in the North & East regions of Los Angeles & Ventura Counties. Twelve medical clinics, including two urgent care centers and dedicated women's centers, are located across the San Fernando, Santa Clarita, San Gabriel and Simi Valleys. The group began as a single medical practice over 90 years ago.
Facey is part of Providence Health & Services, an integrated, not-for-profit 5-state network of hospitals, care centers, medical clinics, affiliated services and educational facilities spanning from California to Alaska.
We offer a full comprehensive range of benefits - see our website for details
As people of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.
Providence Health & Services is the third largest not-for-profit health system in the United States. Providence employs more than 82,000 caregivers (employees) across a five-state area; AK, WA, MT, OR, and CA. Our facilities include 34 hospitals, 600 physician clinics, senior services, supportive housing and other health and educational services. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.