RN Quality Management Case Manager

This Health Plan is a "Medicare Advantage" HMO, serving the needs of over 80,000 seniors in approved zip codes within four Southern California counties including Los Angeles, San Bernardino, Riverside, Orange, Kern and Ventura.  Founded in 1977, this company is a not-for-profit organization with headquarters in Long Beach, California. 

 

Ensures that client and its contracted network provide timely, appropriate quality of care and service to our members and overseeing the quality improvement activities conducted by the client quality improvement staff.

 

Responsibilities:
Processes Grievances, Appeals, Quality Referrals, and Occurrences by establishing the issues of the case, ordering and collecting needed documents, reviewing the case documents, completing the Case Summary, and leveling the case or reviewing the Case with the Medical Director as appropriate.

 

Requirements


CA RN license required - Current and in good standing Degree in a related health care field preferred, at least 5 years clinical exp., at least 3 years exp. in Utilization Management, Quality Management, Risk Management. Excellent Critical thinking skills, 3 years with Managed Care, MS Word, Excel type 40 wpm