Large managed care company looking to fill a contract position lasting through the beginning of May.
This is an on-site inpatient concurrent review position at Acute Hospitals. Case Manager will telephonically manage 1 - 2 Acute Hospitals (dependent on census) and perform concurrent review on patients of medical group.
Can be either RN or LVN. Needs to have prior experience with Concurrent Patient review in an Acute Hospital or Skilled Nursing Facility (SNF) setting. Experience with Referral/Authorization management in a Managed Care setting is a plus.
Position Description:
Collect case specific member information, review and certify the medical necessity of prospective, concurrent, and retrospective units of inpatient and outpatient services. Review each case and determine the most appropriate services, the most appropriate setting in which the services should be delivered, the most cost efficient methods for care of delivery, and the need for planning subsequent care for contracted members and their eligible dependents as assigned. Providing clinical and managed care expertise, as well as Medical Director/physician consultation. Provide first level clinical review for all inpatient and outpatient services requiring authorization for assigned client group regarding: Prospective Review Urgent/ Non-urgent, Concurrent Review, Early initiation of discharge coordination, Analyze case-specific patient information. Verify eligibility, as applicable, and past utilization history. Client-specific protocol and procedures Maximize referrals to network providers. Identifying and reporting quality of care issues. Answer telephone calls promptly as scheduled and as needed. Maintain working knowledge of all client groups Demonstrate adequate competence in computer software use in daily activities. Review case-specific patient information concurrently for the medical necessity of Acute Hospital admissions using commercial review criteria and/or scripted guidelines. Based on severity or complexity of the enrollee's condition, ability to meet commercial review criteria and or scripted guidelines, the necessary treatment, and the discharge planning activity (not routinely conducted on a daily basis), the nurse reviewer will assign the appropriate LOS days/ visits/ services in review of the clinical information obtained. Telephonic discussions with health care providers and members to explain medical necessity determinations and to obtain additional clinical information. Review clinical coverage reviews and assure client recommendations, as designated. Manage workload to ensure timely processing per state and federal mandates
Other duties as assigned.
Qualifications include:
Active LPN or RN nurse licensure; minimum of 1 year clinical experience in an acute care setting Previous Utilization Management experience preferred, Sound clinical judgment, Demonstrated understanding of managed care concepts, Strong problem solving and decision making skills, Strong departmental team player, Good written and verbal communication skills, Personal computer skills, Strong time management and prioritization skills, Excellent customer service skills including a sense of urgency and ownership for resolving issues, Ability to be flexible, adjust quickly and react positively to change, Positive attitude and good work ethics.
What are the hours? ( Training hours?) Work hours generally 8:30 am to 5 pm. No weekends. Training is dependent on prior experience, maybe 1 – 2 week. Trying to find persons who already have this skill set and just need to learn our process.
Interview can be telephonically.
Role will be remote, may have to do some training onsite but after training will be remote, telephonically