Functions as the liaison for hospital staff, PCP, other healthcare team members and BMCHP staff telephonically. Educates network providers on Plan benefits and network services. Responsible for maintaining current knowledge of the developments in medical technology, and legislation pertinent to managed care settings, patient rights, safety regulations and BMCHP contractual and organizational specific requirements.

KEY FUNCTIONS/RESPONSIBILITIES:

• Determines the medical necessity of the acute inpatient, skilled nursing, and acute rehabilitation stays according to established criteria and telephonically coordinates transfers to participating facilities according to certain factors, such as patient condition, and network resources. 
• Monitors patients’ lengths of stay and documents pertinent clinical information for cases referred to Care Management or Plan Medical Director, within required timeframe guidelines.
• Identifies and manages those members who do not meet Hospital Level of Care (HLOC) per BMCHP policy, while notifying appropriate providers of the specific cases and maintaining documentation.
• Conversion of Hospital Level of Care admissions to Administratively Necessary Days or Observation status.
• Anticipates member’s post discharge needs and is proactive in conducting preadmission reviews for admission to skilled nursing facilities and acute rehabilitation facilities. (Note:  New Hampshire processes will need to be followed regarding lower levels of care.)
• Assists providers in effectively providing inpatient discharge planning.
• Participates in or leads clinical quality projects along with the Division of Medical Assistance and New Hampshire quality goals.
• Provides mentoring and guidance to Inpatient UM Specialists to ensure timely discharges, RC2 Upgrades and High Cost Referrals.
• Refers to CM any member that meets the established guidelines.

QUALIFICATIONS:

EDUCATION:

• Bachelors Degree in Nursing or Nursing School Degree with equivalent relevant work experience.
• CCM certification preferred.

EXPERIENCE:

• 3 years related experience in an acute care or health insurance environment.
• 2 years experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning.

PREFERRED/DESIRABLE:

• Experience in acute care and/or rehab nursing.
• Experience with Medicaid recipients and community services.
• Experience with FACETS, CCMS, InterQual™ or other healthcare database.

CERTIFICATION OR CONDITIONS OF EMPLOYMENT:

• Current MA state licensure as a Registered Nurse.

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

Required Skills Required Experience

+--------------------------------------------------------------------------+ | KNOWLEDGE, SKILLS, & ABILITIES | +--------------------------------------------------------------------------+ | - Knowledge of communication system and maintenance practices needed | | to inspect, test, install, and maintain Metro's | | Communication systems. | | - Knowledge of PC based computer hardware, Microsoft computer | | operating systems, and computer networking at the | | administrative level. | | - Knowledge of standard PC based software programs and tools such as | | Visual Studio, Oracle, MS Access, and hardware | | diagnostic applications. | | - Knowledge of railroad / rail transit communication system operation. | | - Knowledge of Metro, local, state, and federal | | communication regulations. | | - Knowledge of the National Electric Code. Skilled at the use of | | industry standard tools and test equipment used in the maintenance | | and installation of communication systems: (Various hand-tools, | | Multimeter, Oscilloscope, OTDR, dB meter, etc.) | | - Skilled at identifying and rectifying communication system (defects) | | and related problems. | | - Ability to evaluate and implement strategies to efficiently and | | effectively troubleshoot and repair communication system failures. | | - Ability to work independently as well as in a team environment. | | - Ability to communicate effectively, both orally and in writing. | | - Ability to use PC based programs Word, Excel, and E-mail. | | - Ability to work in any weather conditions, at any time of the day | | or night. | | - Ability to report for emergency duty 24/7. | | - Ability to walk at least twenty miles per week over ballast track | | and uneven surfaces. | +--------------------------------------------------------------------------+