Impact Lives, Impact Community

Family Health Centers of San Diego (FHCSD) is passionate about providing exceptional health care to all, especially underserved communities with limited health care options. Founded by a Latina grandmother/community advocate over 50 years ago in Barrio Logan, FHCSD has grown into one of the largest community health systems in the country. With over 62 sites, over 227,000 patients, and over 417,000 visits last year, we provide a wide variety of health care and outreach services to a very diverse patient population. We are proud of our mission, our lasting community impact, and the cultural and individual diversity of our staff.

Job Roles

• Develop prospective, initial and retrospective reviews on all inpatient, facility, skilled nursingservices assessing for appropriateness and medical necessity of the treatment requests.
• Assess quality and clinical risk issues on a concurrent basis; reporting any recognized issues to the team andAssistantMedical Director.
• Proactively provide input to participants' care plan for managing chronic and acute illnesses with the intent of improving quality outcomes and decreasing costs.
• Proactively manage acutely and chronically ill patients to improve quality outcomes and decrease costs.
• With Assistant Medical Director, evaluate and provide feedback as needed to treating physicians related to participants' discharge and home care plans and available covered services to include identifying alternative levels of care that may be covered.
• Develop strong working relationships with outside contracted providers, case managers, and admissions department or personnel.
• Assess documentation of medical records for completeness and relationship to the treatment plan to identify gaps or barriers in treatment plans.
• Facilitate on-going communication between staff and contracted providers to ensure authorizations are secured in a timely and efficient process.
• Coordinate care and services as needed (hospitalization, skilled care, home health, DME, etc.) to include making referrals to outside sources.
• Coordinate identification and reporting of potential high dollar utilization cases.
• Work with QA in preparing compliant notification letters of NON-certified certification and negotiated days and services within established timeframes. Review all NON- certification files for correct documentation.
• Coordinate an interdisciplinary approach to support continuity of care. Provide utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed by members.
• Assist in identification and reporting of potential quality of care concerns. Ensure these issues are reported to the Quality Improvement Department.
• Investigate and follow-up on complaints, grievances and quality issues related to patient acute or skilled level stays.
• Participate in Utilization Management team meetings, review and discuss with providers evidence-based care options, and propose alternative levels of care.
• Perform other duties as assigned.

Education/Certifications/Licenses/Registrations

• Current California RN license.
• BSN or MSN degree preferred.
• Ability and means to travel as needed in a timely manner within San Diego County, to locations that may have limited access to public transportation; proof of liability and property damage insurance on vehicle used is required. DRIVER REQUIREMENTS: Age 21; Licensed for a minimum of 3 years; No violations and/or accidents within 3 years; No vehicle related suspensions/reinstatements; No DUI, reckless or felony Driving within 7 years.

Experience/Specialized skills (including Language)

• 2 - 4 years of experience working in a managed care health plan or
• 2 - 4 years of experience in utilization review, case management, and discharge planning or
• 2 - 4 years of experience in transitional care and acute care settings (critical care, acute hospital care, long term acute care, skilled nursing care, long term care).
• Knowledge of and/or experience with Managed Care Health plans, Medi-Cal/Medicaid, and/or Medicare required.
• Ability to work independently and as an effective member of a team.
• Ability to multi-task related to projects and their respective activities, timelines and issues.

• Prefer

• Knowledge of PACE regulations (state and federal).
• Principles and practices of health care service delivery, managed care, health care systems, and medical administration.
• Experience performing audits analyzing productivity and quality of utilization management.
• Knowledge and/or experience with the senior care market, to include competitors, regulations, and available resources.
• Experience in the application of the InterQual criteria or other evidence-based medical criteria.

Physical Requirements/Working Environment

Bending (neck): OCCASIONALLY (1 - 3 HRS)

Bending (waist): RARELY (0-1 HRS)

Carrying 0 - 10 lbs: RARELY (0-1 HRS)

Carrying 11 - 25 lbs: NEVER

Carrying 25 - 50 lbs: NEVER

Carrying 51 - 75 lbs: NEVER

Carrying 75 lbs: NEVER

Climbing (ladder): NEVER

Climbing (stairs): RARELY (0-1 HRS)

Driving: To drive from one clinic or another, or in the community: REGULAR DRIVING (MORE THAN 3 DAYS PER WEEK)

Exposure to blood borne pathogens and biohazards: NO

Exposure to dust, gas, fumes, or chemicals: Office supplies

Fine manipulation: OCCASIONALLY (1 - 3 HRS)

Kneeling: RARELY (0-1 HRS)

Lifting 0 - 10 lbs: RARELY (0-1 HRS)

Lifting 11 - 25 lbs: NEVER

Lifting 25 - 50 lbs: NEVER

Lifting 51 - 75 lbs: NEVER

Lifting over 75 lbs: NEVER

Power Grasping: OCCASIONALLY (1 - 3 HRS)

Pulling 0 - 10 lbs: OCCASIONALLY (1 - 3 HRS)

Pulling 11 - 25 lbs: RARELY (0-1 HRS)

Pulling 25 - 50 lbs: RARELY (0-1 HRS)

Pulling 51 - 75 lbs: NEVER

Pulling over 75 lbs: NEVER

Pushing 0 - 10 lbs: RARELY (0-1 HRS)

Pushing 11 - 25 lbs: RARELY (0-1 HRS)

Pushing 25 - 50 lbs: RARELY (0-1 HRS)

Pushing 51 - 75 lbs: NEVER

Pushing over 75 lbs: NEVER

Reaching (above shoulder level): RARELY (0-1 HRS)

Reaching (below shoulder level): RARELY (0-1 HRS)

Repetitive use of hand: CONSTANTLY (6+ HRS)

Simple Grasping: OCCASIONALLY (1 - 3 HRS)

Sitting: CONSTANTLY (6+ HRS)

Standing: OCCASIONALLY (1 - 3 HRS)

Twisting: RARELY (0-1 HRS)

Use of Personal Protective Equipment: N/A

Walking: OCCASIONALLY (1 - 3 HRS)

Working around equipment and machinery: Office equipment

Ages of Patients Served: N/A

In the spirit of pay transparency, we are excited to share the base range for this position, exclusive of fringe benefits or potential bonuses.

If you are hired at Family Health Centers of San Diego, your final base salary compensation will be determined based on factors such as geographic location, jurisdictional requirements, skills, education, and/or experience. In addition to these factors - we believe in the importance of pay equity and consider internal equity of our current team members as a part of any final offer. Please keep in mind that the range mentioned above is what we reasonably expect to pay for the role. Hiring at the maximum of the range would not be typical in order to allow for future and continued salary growth. We also offer a generous compensation and benefits package (more information on our benefits offerings is available here: FHCSD Wellness - Employee Hub (gobenefits.net)