Case Management Nurse

Responsible for supporting the clinical Utilization Management activities for members. Conducts medical necessity review of referral requests including but not limited to requests for DME, outpatient therapies, and prior authorizations for outpatient procedures and prospective inpatient stays. Utilizes Milliman and Medicaid criteria to facilitate decision making. Refers cases to the Medical Director when clinical information does not support medical necessity. Functions as a key resource to the Non-Clinical Intake Coordinators for questions or clarifications on criteria, interpretation of benefits, or whenever they need additional clinical expertise and/or guidance

Performs review of requested outpatient and elective, prospective inpatient medical services. Under the direction of the UM Outpatient Clinical Supervisor coordinates and refers members for services which are carved out of KHS medical coverage. Assists in the authorization and processing of automatic referral requests. Collaborates with the KHS Member Service Department and the Provider Relations Department regarding quality of care and other grievance issues to facilitate timely problem resolutions. Utilizes clinical guidelines as well as Medi-Cal criteria to review outpatient service requests for medical necessity and benefit coverage while processing referral request. Identifies and refers cases for quality of care, coordination of benefits, and third-party liability issues as appropriate. Identifies and refers cases appropriate for various internal programs. Shares information as necessary with appropriate Population Health Management team: Case Management, Transitions of Care, Major Organ Transplant and Community Support Services including but not limited to Extended Care Management.