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Medical Management Specialist - RN

Pay38.61 - 61.78 / hour
Employment typeFull-Time

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  • Job Description

      Req#: MEDIC006031
      *Sunday - Thursday, 8am-5pm Pacific Time Zone

      *CA RN

      About SCAN

      SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 270,000 members in California, Arizona, Nevada, Texas and New Mexico. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit,, or follow us on LinkedIn, Facebook, and Twitter.

      The Job

      The Medical Management Specialist's purpose at SCAN is to ensure that systems and resources are available to meet the medical and behavioral health care needs of our members in a timely and cost-effective manner. These items and services are evaluated for medical necessity and appropriateness based on severity of illness and the site of service by SCAN and/or contracted Provider Organizations. This role monitors utilization trends and patterns for over- or under-utilization and inefficient use of resources, conducts telephonic and/or on-site prospective and concurrent review, provides discharge planning services, and establishes intervention action plans. Communicates with providers and ensures collaborative work processes with Provider Organization (PO) partners (both in network and out of network/out of area) to establish action plans.

      You Will

      Ensures that clinically appropriate inpatient and outpatient care and other services are rendered to SCAN members at the right time, at the right level of care and at the right location by co-managing complex medical and behavioral health cases, with provider organization case management and utilization management staff.

      Applies evidenced-based criteria and guidelines as well as clinical judgment and expertise to assess treatment plans.

      Consults with a SCAN Medical Director when needed, and offers recommendations to the care team for medical and/or behavioral health management at the appropriate level of care.

      Refers cases that do not meet established criteria to the SCAN Medical Director for secondary review.

      Manages complex medical cases by applying the essential activities of case management and utilization management including assessment, planning, implementation, coordination, advocating, monitoring, and evaluation.

      Assists members who require urgent and emergent medical and behavioral health services while outside the network or the SCAN service area, by working directly with members, caregivers, and providers to ensure the provision of quality, coordinated care. Authorizes care and services needed for stabilization and when appropriate, works to transition members and services back into the SCAN provider network.

      Facilitates safe and effective discharges from inpatient settings by communicating member needs and issues identified during the course of inpatient treatment to other members of the care team including but not limited to SCAN Care Management staff, medical group case managers, and Primary Care Physicians (PCPs).

      Utilizes department desktop procedures, workflows, job aids and training material. Identifies barriers to work processes and brings to the attention of the supervisor/manager.

      Builds effective professional relationships with providers and other internal and external partners utilizing verbal and written communication skills, developing trust, meeting timelines, respecting cultural differences, using active listening skills, and maintaining confidentiality.

      Provides insight into the management of chronic conditions to providers and hospitals. Assists providers to support members/caregivers with end of life planning by providing information, education and referral sources related to advanced care planning.

      Acts as a resource to care managers, discharge planners, physicians and other members of the health care team.

      Enhances Provider Organization (PO) performance as it relates to inpatient care by coaching PO counterparts on inpatient acute and skilled nursing geriatric care and by identifying and logging issues.

      Participates in PO medical management meetings and supports follow up identified activities.

      Provides and applies member interventions known to impact Quality measures.

      Addresses urgent member quality or access to care issues via the Member Quality Intervention (MQI) process.

      Ensures that health care services are being provided to SCAN members by network providers and if not, when applicable, works to transition members and services to network providers.

      Completes timely written documentation, showing evidence of all concurrent review, discharge planning and case management activities.

      Facilitates quality of care and service by identifying and referring potential quality issues to the Quality Management Department and/or SCAN Medical Director.

      Prepares and delivers case presentations, participates in case rounds and interdisciplinary team meetings (IDT) and incorporates IDT recommendations into member's care plan.

      Maintains the member's right to privacy and protects SCAN operations by keeping information confidential.

      Adheres to all quality, compliance and regulatory standards to achieve HCS and SCAN outcomes.

      Maintains professional and technical knowledge by attending educational workshops, reviewing

      professional publications, establishing personal networks, participating in professional societies.

      Contributes to the team effort by accomplishing related results as needed.

      Field/onsite work may be required based on business need.

      Actively support the achievement of SCAN's Vision and Goals.

      Other duties as assigned.

      Your Qualifications

      Graduation from an accredited school of nursing. Bachelor's degree in Nursing or related field required.

      Current and active CA RN License is required.

      Case Management Certification (CCM), Accredited Case Management (ACM) or Certified Professional of Utilization Management (CPUM) is preferred.

      3 - 5 years of experience in medical-surgical nursing preferred.

      3+ years of concurrent review, case management, and prior authorization experience in a medical group, IPA or HMO setting is preferred.

      Basic knowledge of related NCQA standards, CMS and DHCS regulations.

      Navigate and access multiple software systems without error.

      Proficient in MS Office Suite.

      Excellent written and oral communication skills, as well as strong interpersonal, critical thinking and analytical skills.

      Excellent organizational, decision-making and multi-tasking skills.

      Demonstrated customer focus; proactively finds ways to exceed customer needs.

      Demonstrates keen attention to detail and produces high quality work products.

      Ability to prioritize multiple and competing tasks, work independently and in a team environment.

      Ability to work well in a fast-paced and dynamic environment.

      Medical and clinical terminology conversant.

      Basic ICD-9/10 and CPT coding knowledge.

      What's in it for you?

      • Base salary range: $38.61 to $61.78 per hour
      • Remote Work Mode
      • An annual employee bonus program
      • Robust Wellness Program
      • Generous paid-time-off (PTO)
      • Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday
      • Excellent 401(k) Retirement Saving Plan with employer match and contribution
      • Robust employee recognition program
      • Tuition reimbursement
      • An opportunity to become part of a team that makes a difference to our members and our community every day!

      We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

      At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

      SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.



      Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

      The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
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