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Utilization Management Admissions Liaison RN II

Job Category:  Clinical
Department:  Utilization Management
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  6227

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Utilization Management (UM) Admissions Liaison RN II is exclusively responsible for receiving admission requests from inpatient facilities, reviewing clinical data in real-time, and issuing a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modifications and denials communications for inpatient admission requests. Actively monitors for appropriateness of admitting level of care (inpatient vs. observation) in the acute care setting. Works with the UM Leadership, including the Utilization Management Medical Director, on cases where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests /referral management and processes.

Duties

Provides the primary clinical point of contact for inpatient acute care hospitals. Ensures appropriate determination for admission requests based on clinical data presented and established criteria/guidelines.

 

Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer.

 

Applies clinical expertise and the nursing process to triage and prioritize admission acuity. Serves as an expert clinical resource for patient placement.

 

Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement.

 

Triages and assesses members for admission needs, including but not limited to, bed and accepting physician availability.

 

Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership.

 

Utilizes medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes.

 

Escalates inpatient admittance appropriately to Medical Director.

 

Completes all inpatient requests appropriately and timely.

 

Performs other duties as assigned.

Education Required
Associate's Degree in Nursing
Education Preferred
Bachelor's Degree
Master's Degree in Nursing
Experience

Required:
Minimum 5-7 years of clinical experience in an acute hospital setting. Strong understanding of Utilization Management/Case Management practices including, but not limited to, placement criteria.

 

Preferred:
Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable.

 

Experience in bed placement decision-making highly desirable.

 

Additional years of preferred experience could be substituted for missing required years of experience.

Skills

Required:
Proven demonstration of ongoing competency skills including age-specific competencies.

 

Proven demonstration of superior critical thinking and problem solving skills, and decision-making abilities.

 

Must possess high proficiency with computer skills, including Outlook and Microsoft Word.


Excellent customer service and communication skills.

Licenses/Certifications Required
Registered Nurse (RN) - Active, current and unrestricted California License
Licenses/Certifications Preferred
Certified Case Manager (CCM)
American Case Management Association (ACM)
Required Training
Additional Information

Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery.

 

Types of Shift:  Day (8:00am - 6:30pm), Evening (5:00pm -3:30am), Night (8:00pm -9:00am), Float (Varies)*
* All possible shift coverage

 

L.A. Care offers a wide range of benefits including

  • Paid Sick Leave
  • 457 (b) Retirement Plan
  • 529 College Savings Plan