Out-Of-Network Utilization Management Rn

Job ID
Employment Type
Full Time
Care Coordination
Hours / Pay Period
Dignity Health System Office
Standard Hours
Mon - Fri
Work Schedule
8 Hour
-Remote Opportunity



Dignity Health, one of the nation’s largest health care systems, is a 22-state network of more than 9,000 physicians, 63,000 employees, and 400 care centers, including hospitals, urgent and occupational care, imaging and surgery centers, home health, and primary care clinics. Headquartered in San Francisco, Dignity Health is dedicated to providing compassionate, high-quality, and affordable patient-centered care with special attention to the poor and underserved. In FY17, Dignity Health provided $2.6 billion in charity care, community benefit, and unpaid cost of government programs. For more information, please visit our website at www.dignityhealth.org. You can also follow us on Twitter and Facebook.




Job Summary:
This position is responsible for improving care management coordination between SSJSA hospital staff and affiliated medical groups and IPA’s by using advanced problem-solving skills, consultation, communication, personal education, and research.  This position is also responsible for providing oversight for out-of-network (OON) cases that are capitated to the Dignity Health hospitals in the GSSJSA and to provide support to the Director, Clinical Partnerships related to managing GSSJSA capitated business.  This position works with affiliated GSSJSA Medical Groups and IPA’s to meet appropriate quality, patient satisfaction, and utilization objectives in a manner consistent with the Mission and Philosophy of DH.  


Dignity Health is committed to showing respect for all people by providing excellent care. That means utilizing the most advanced medical technology. It means working closely with our patients so they can lead healthy, meaningful lives. And, of course, it means doing all of this with compassion – the kind of compassion that includes finding ways to deliver high quality care at the lowest possible cost, so it’s accessible to all.



1 Planning and Managing
• Locate and coordinate care for Dignity Health members who are in the Emergency room or hospitalized inpatients outside the Dignity Health system.
• Locate and coordinate resources for members who are returning to the Dignity Health system (repatriation).
• Coordinate care on complex cases where hospital and/or medical group are at risk.
• Measure performance of case management for the high risk and high opportunity patients.
• Identifies complex/problematic system issues related to care management and involves the multidisciplinary team to improve quality and appropriate resource allocation.
• Collaborates with Case Management Leadership in maintaining compliance with requirements of regulatory agencies.
• Provide monthly and or quarterly reports related to out of network (OON) utilization with comparison to objectives for all affiliated medical groups.
• Share monthly and/or quarterly reports related to OON utilization with appropriate affiliated medical groups and as appropriate interact with Joint Operating Committees to meet objectives.
• In collaboration with the Director, Clinical Partnerships, develops and implements programs to enhance the quality and profit margins of the organization.
• Focuses on high volume, high risk patient populations and/or DRG groups to identify opportunities to improve patient outcomes and reduce unnecessary resource utilization.
• Assesses cases and contracts utilizing knowledge of current legal, accreditation, and regulatory requirements.
• Accurately communicates with providers about the diagnosis and severity of illness to determine appropriate levels of care.
• Coordinates transfers via DH transfer center of out of network capitated patients to the appropriate level of care.
• Coordinates concurrent review for patients at non DH facilities with affiliated medical groups to reduce out of network expenses for DH.
• Assists in verifying case data for each facility to provide correct medical group risk payment and prevent discrepancies.
• In conjunction with the Medical Directors of medical group/IPA/health plan, provide information to case management for OON patients in need of care post hospitalization.
• Provide daily/weekly/monthly OON reports/updates to Director, Clinical Partnerships and others as required for analysis at Purchased Services Committee, Steering Committee and other utilization management committees as needed.

2 Analysis and Reporting
• Provide leadership for assigned projects by means of expert and research based knowledge and achieve agreed upon outcomes.
• Collaborate with hospital case management to implement and maintain processes for regulatory compliance.
• Integrate quality improvement processes within case management care coordination.
• Monitors and updates current data collection activities.
• Monitors open issues from all activities, groups and committees.
• Provide a consultative relationship with affiliated medical group and IPA care management personnel and management focusing on mobilizing internal and external resources to solve problems through planned change.
• Applies utilization management skills in day to day reviews using approved medical necessity criteria.

3 Communicating and Training
• Collaborate with all levels of the health care team to support and contribute to management/organizational goals for quality patient care.
• Communication to DH transfer center of patients stable for re-patriation into a DH facility from various sources, ED, NICU, trauma, med-surg, pediatrics etc. in a timely manner taking into consideration appropriate resource utilization.
• Keep abreast of the continually changing regulations affecting the industry to facilitate improving the quality of services rendered.
• Work closely with affiliated IPA and Medical Group Medical Directors and key physician leaders (i.e trauma, NICU, pediatrics) to identify needed changes in practice and/or referral patterns and to assist in their modification to achieve desired outcomes.
• Communicates progress and challenges to Director, Clinical Partnerships and other members of DH utilization management department.





Experience: JCAHO and State and Federal Regulations.  Coding, documentation, DRG’s.  Case Management models and standards.  Nursing theory and practice standards.  Research models.  Continuous quality improvement methods.  Knowledge of reimbursement under Medicare, MediCal and private insurance, Capitation including Medical group/physician implication.  Case management of capitated at-risk patients.  Knowledge of the meeting process.


• Current California nursing licensure.
• Five years experience in utilization review and discharge planning, case management and managed care. 
• A baccalaureate degree in nursing, business or equivalent or a combination of knowledge and experience that adequately prepares the individual to competently perform the job
• Certification in Case Management  


Special Skills: 
Self-starter and works independently.  Organizational and management skills.  Qualitative data collection methodologies and analytical analysis.  Problem solving skills.  Effective interpersonal communication skills.  Interpret contracts for benefit analysis as appropriate.


Interpersonal Relationships:
Must have excellent interpersonal skills to effectively build relationships within and outside the organization. Has regular contact with a variety of audiences including front line staff, management/senior management, physicians and other Dignity Health Divisions and Corporate staff. Has periodic contact with representatives of outside agencies.


Reporting Relationships: Reports to Director, Clinical Partnerships SSJSA.

Travel: As needed




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