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Utilization Review/Case Management RN

Pyramid Consulting, Inc

Santa Clara, CA

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JOB DETAILS
SALARY
$75–$85 Per Hour
SKILLS
Analysis Skills, Artificial Intelligence (AI), Case Management, Communication Skills, Community and Social Services, Consulting, Content Management Systems (CMS), Cross-Functional, Customer Support/Service, Discharge Plans, Documentation, ERISA (Employee Retirement Income Security Act of 1974), Employee Benefits, HIPAA (Health Insurance Portability and Accountability Act), Health Education, Health Plan, Healthcare, Healthcare Providers, Hospital, Medi-Cal, Medicare, National Committee for Quality Assurance (NCQA), Nursing, Nursing Credentials, Patient Care, Problem Solving Skills, Quality of Care, Registered Nurse (RN), Regulations, Regulatory Requirements, Short Messaging Service (SMS), Social Work, State Laws and Regulations, Utilization Management, Willing to Travel, Word Processing
LOCATION
Santa Clara, CA
POSTED
30+ days ago
Immediate need for a talented Utilization Review/Case Management RN. This is a 03+ Months Contract opportunity with long-term potential and is located in Santa Clara, CA (Onsite). Please review the job description below and contact me ASAP if you are interested.

Job ID:25-96149

Pay Range: $75 - $85/hour.  Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).
 
Key Responsibilities:
  • Utilization Management:-Performs daily pre-admission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge.
  • Monitors the progression of the discharge plan and facilitates discussions with the multidisciplinary teams.
  • Educates other healthcare team members on utilization and care coordination.
  • Collaborates with and provides information to patients, families, physicians, and staff regarding the discharge plans and transitions.
  • Understands and consistently applies the interpretation, and utilization of member health care benefits.
  • Conducts UM, care coordination and discharge planning activities according to all applicable regulatory requirements.
  • Discharge Planning:- Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient.
  • Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other health care providers and agencies.
  • Regulatory:-Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements.
  • Shift Timings: 8:00 AM – 4:30 PM – 5 days/week including every other weekend (both Saturday & Sunday). 
  • Days vary but we are looking for 2 travelers to fill the schedules below:
  • Traveler            Week 1 Schedule                Week 2 Schedule
  • Traveler 1    Mon, Tue, Wed, Fri, Sat               Sun, Mon, Wed, Thu, Fri
  • Traveler 2    Mon, Tue, Thu, Fri, Sat                Sun, Tue, Wed, Thu, Fri
Key Requirements and Technology Experience:
  • Skills-Recent hospital/acute care setting experience
  • Strong discharge planning background
  • Availability aligned with the outlined shift schedules
  • Minimum two (2) years of experience in utilization review, case management, and discharge planning.
  • Graduate of accredited school of nursing.
  • Diploma/Associate Degree in Nursing.
  • License, Certification, Registration:-Registered Nurse License (California) – Required upon hire.
  • Basic Life Support (BLS) – Required upon hire.
  • Knowledge of the Nurse Practice Act, TJC, DMHC, CMS, NCQA, HIPAA, ERISA, EMTALA & all other applicable federal/state/local laws & regulations.
  • Demonstrated strong communication and customer service skills, problem-solving, critical thinking, & clinical judgment abilities.
  • Fundamental word processing & computer navigation skills & the ability to interpret & use analytic data in day to day operations.
  • Knowledge of health care benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.).
  • Must be able to work in a Labor/Management Partnership environment.
  • Acute inpatient hospital-level experience.
  • Bachelor's degree in nursing or a health care related field preferred.
  • Master's degree in case management preferred.
Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.
 
Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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Pyramid Consulting, Inc

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