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GENERAL DESCRIPTION OF POSITION The Utilization Management and Discharge Planning Nurse performs clinical review in accordance with applicable regulatory and professional standards for Organization Determination Requests using clinical experience and skills in a collaborative process to assess, plan, implement, coordinate and evaluate options to ensure appropriate utilization of member healthcare services and benefits for all lines-of-business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective/claims review organization determination authorization requests within regulatory turnaround requirements for all SCFHP lines of business. Complete authorization reviews by applying the appropriate clinical criteria/guidelines, policy, procedures and clinical judgment to render coverage determinations. Document pre-admission status, including living arrangements, physical and mental function, social support, durable medical equipment (DME), and other services received. Draft appropriate notification letters such as approval, denial, delay and modify notifications to providers and members and language threshold following regulatory requirements. Perform onsite concurrent review activities, as needed in the home, facility or community setting. Review and monitor hospital or nursing facility census and internal reports to track, reconcile and update discrepancies in member case files. Facilitate and coordinate communication related to post discharge with member interdisciplinary care team (ICT) including physicians, specialists, public services, community agencies and vendors to ensure care plan development and coordination of benefits and services. Apply the use of clinical judgment to identify and coordinate referrals to appropriate departments or programs for member identified continuity of care needs, such as Case Management, Behavioral Health, Managed Long Term Services and Supports (MLTSS), community resources, Pharmacy and Quality. Proactively and collaboratively interface with external case management staff including delegates to facilitate discharge planning and care transitions. Maintain adherence with Model of Care of CMC, LTSS and DHCS regulatory requirements.

REQUIREMENTS – Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

Active California Board of Nursing License (RN) without restriction. (R) Minimum one year of licensed related health care experience. (R) Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management. (R) Knowledge of MediCal and/or Medicare guidelines and regulations. (D) One year of experience with a Managed Care Health Plan. (D) Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards. (D) Ability to make determinations based on Nursing knowledge when no criteria are available or applicable. (R) Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R) Clinical knowledge and critical thinking skills with the ability to assess individualized whole-person care needs necessary to develop an effective care plan. (R) Experience working with designated member population (e.g. behavioral health, seniors and persons with disabilities, children). (D)

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.