The Managed Care Utilization Management includes the responsibilities of Utilization Management for the HMO capitated membership assigned to the UC Davis Medical Group. The Department interacts daily with UC Davis Health System physicians and staff, including Clinical Case Management, and Ambulatory Case Management, Provider Relations, Health System Contracts, UC Davis Primary Care Network medical directors and staff and Managed Care Operations Department (Claims and Member Services). The Utilization Management (UM) function of the department insures services/care rendered to UC Davis Medical Group capitated members are medically necessary/appropriate and in conformance clinically with the benefits of the member’s health plan coverage.

Job Summary

We offer exceptional employment benefits including medical, dental, and vision plans, generous paid vacations and holidays, excellent retirement savings and investment plans, continuing education, and reduced fee and scholarship programs.

THIS IS NOT AN H1- B OPPORTUNITY

Job Responsibilities:

The Case Manager performs utilization review for inpatient UC Davis capitated patient, patients admitted to external hospitals and review appropriateness of outpatient services (prior –authorizations). The Case Manager’s work is performed independently. The Case Manager will receive direction concerning the overall goals and objectives of the department and will participate in action to achieve those goals.

Required Qualifications:

• Valid California Registered Nurse License without restriction.
• Graduation from an accredited School of Nursing or BSN required for external candidates.
• Minimum 1-3 years knowledge and experience with medical necessity reviews using an evidence-based criteria such as, Milliman or InterQual or health plan medical policies

Preferred Qualifications:

• Broad-based clinical experience as a registered nurse in multiple outpatient and inpatient clinical settings within an HMO Health plan or Medical Group/IPA.
• Experience in identifying and analyzing care/service needs for case managed patients
• Skills to perform in-depth chart analysis to provide accurate information in a concise, informative manner.
• Knowledge of care/services provided in differing levels of care, i.e., ambulatory and institutional settings.
• Knowledge of medical and nursing treatment plans.
• Skill in assessing the appropriateness and medical necessity for acute and SNF admissions and continued stays.
• Clinical skills and knowledge to assess type and amount of home health care necessary to meet patients’ needs in the home setting.
• Analytical skills to identify and obtain pertinent data from multiple sources, accord each piece of information the appropriate weight and consideration, and reach the appropriate logical conclusions/recommendations.
• Effective time management skills to accommodate special projects, deadlines, and priorities.

Special Requirements

This position may be subject to a criminal background investigation, drug screen, Live Scan fingerprinting, medical evaluation clearance, and functional capacity assessment.

The University of California has implemented a SARS-CoV-2 (COVID-19) Vaccination Program SARS-CoV-2 Vaccination Policy (ucop.edu) covering all employees. To be compliant with the policy, employees must submit proof of vaccination or a University-approved exception or deferral.

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We recognize that creating an inclusive and intellectually vibrant organization means understanding and valuing both our individual differences and our common ground. The most comprehensive solutions come from the most diverse minds, and you belong here.

As you consider joining UC Davis, please explore our Principles of Community, our Clinical Strategic Plan and strategic vision for research and education, and our latest efforts to outgrow the expected.

The University of California is an Equal Opportunity/Affirmative Action Employer advancing inclusive excellence. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected categories covered by the UC nondiscrimination policy.