AppleCare Medical Management Group was incorporated in 2003. Over the last 17 years, the multispecialty medical group of independent practices has expanded into new communities, contracted with more hospitals and health plans, and added over 50 new doctors - but the mission has remained the same. Today, AppleCare Medical Management is comprised of hundreds of board - certified private - practice, independent physicians. Collectively, our physicians have been serving the Southeast area of Los Angeles and Northern Orange County for decades, providing their medical expertise and passion to improving the health of our communities. As a part of our continued growth, we are searching for a new Case Manager to join our team.As a Case Management Nurse you will be responsible for helping our members to properly utilize our health services and maximize their benefits. You will be tasked with assessing and interpreting member needs and identifying solutions that will help our members to live healthier lives! This is an inspiring job at a truly inspired organization. Ready for a new path? Join us and start doing your life's best work.(sm) Primary Responsibilities:Perform case management services for our members Determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination Assess and interpret patient needs and requirements Identify solutions to non - standard requests and problems Work with minimal guidance; seeks guidance on only the most complex tasks Translate concepts into practice Provide explanations and information to others on difficult issues Coach, provide feedback, and guide others Act as a resource for others with less experience
Required Qualifications: Undergraduate degree or equivalent experience Active RN or LVN license in California 1+ years of experience in managed care environment, preferably in an IPA or MSO (Other case management or UR experience will be considered) Knowledge of HMO, CM, UM, and QM Processes Knowledge of and experience with the Case Management, UM criteria such as Milliman & Robertson, Medicare and Medicaid guidelines, health plan criteria, etc. Preferred Qualifications: RN license preferred Bilingual Spanish preferred General knowledge of IPA Operations There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm) What makes your nursing career greater with UnitedHealth Group? You can improve the health of others and help heal the health care system. You will work within an incredible team culture; a clinical and business collaboration that is learning and evolving every day. And, when you contribute, you'll open doors for yourself that simply do not exist in any other organization, anywhere. Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Job Keywords: RN, Registered Nurse, LVN, UR, CM, UM, Case Management, Case Manager, Utilization Management, Concurrent Review, Milliman, Interqual, Managed Care, Insurance, Discharge Planning, Chart Review, Pre-Authorization, La Palma, CA, California
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.