Utilization Review Nurse (CCS Experience)

CCS Case Manager performs case reviews for CCS eligibility. They are responsible to assess, plan, implement, monitor, and evaluate options and services to develop a patient focused action plan. The CCS Case Manager acts as patient advocate through the process and is available to the physician, patient and family as a resource to facilitate communication.

Applies California Children Services policy and follows State guidelines in the issuance of CCS services. Reviews discharge summary/instructions and oversees CCS Care Coordinator to arrange member’s post-discharge follow-up visits with PCP and/or Specialists. Reviews medical records and contacts the member or member’s parent/guardian to assess member’s social and health related needs/concerns. Creates care plan goals to be discussed with member or member’s parent/guardian Makes sure that member or member’s parent/guardian is aware that member has an active CCS case and the benefits of CCS program Oversees CCS Care Coordinator as they arrange appointments with the specialist & PCP office, and to check status of ancillary services like DME, therapy, Home Health if already provided to the member. Generates CCS referral for the CCS coordinator in submitting SAR to CCS with supporting medical documentation. Perform retroactive claims review on all CCS diagnoses. Respects the dignity, confidentiality and privacy of each patient and adheres to HIPAA regulations and policies. Gathers and organizes monthly, quarterly and annual CCS reporting logs within established timeframe Collaborate and participate in all Health Plan and DHCS audits Coordinates and completes special projects as delegated by the VP of Care Management