This position is responsible for answering and routing calls to support the Blue Touch Point process, including warm transfers to/from customer service and care management. This position is responsible for the scheduling of telephonic call backs for both care management and pre-cert departments. The nurse will be available to answer calls in a queue setting, triage the needs of the caller, and then route to the appropriate person and/or POD based on staffing availability. The Nurse Navigator works in conjunction with the integrated Walmart Service Team, the initial clinical information collection for trigger diagnoses and clinic review of hospitalizations and other referrals for Care Management referral and intervention as needed. The incumbent consults with Customer Service, Pre-Cert Area and Care Managers on issues impacting the delivery of cost-effective quality health care, including referral to Care Management as required.
Nature & Scope
The incumbent is responsible for implementation of the pre-cert process and referral program, including the building of CSW inquiries, referral review, data gathering, provider education, data entry to maintain referral log, and notification of potential subrogation.
Minimum Job Requirements
1. Current LPN license in the State of Arkansas.
2. Experience in medical surgical nursing.
3. Utilization Management experience i.e. precertification, utilization review, and /or concurrent review preferred.
4. Previous work experience in home health (in-take nurse), physician/hospital setting, and/or insurance setting desired.
5. Type 40 wpm.
6. Ability to use a PC with software (i.e., Word and Excel).
7. Working knowledge of CPT, ICD codes, and medical terminology is necessary.
This position is identified as level three (3). This position must ensure the security
and confidentiality of records and information to prevent substantial harm, embarrassment,
inconvenience, or unfairness to any individual on whom information is maintained.
The integrity of information must be maintained as outlined in the company Administrative
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented
or detected on a timely basis by employees in the normal course of business. This
position must adhere to the segregation of duties guidelines in the Administrative
PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
1. Implements the Care Management referral process which includes utilizing the CPT-4 codes, ICD-9 codes, and assisting with care management activities.
• Receives and records pre-certifications for inpatient admissions to SNF, LTAC, Acute Inpatient Rehab and Hospice via telephone, fax, and other referral sources. Screens and identifies appropriate patients for referral to care management, based on information received from pre-cert nurses. Contacts SNF, LTAC, Acute Inpatient Rehab and Hospice for additional clinical information as needed. (Information is recorded in an accurate and complete manner.)
• Receives and routes member and provider calls to appropriate person/POD based on needs of caller.
• Responsible for the scheduling of telephonic call backs .
• Verifies member eligibility, contract benefits, PCP assignment, and facility participating status.
• Completes data entry for referral identification, determination, and communication with all members of the Medical Management staff.
• Maintains referral log for care management via Power.
• Assists with Care Management activities and data entry as requested by care managers. This includes discharge data and referral documentation.
• Monitor and assess LOS for possible discharge needs and/or referral to care management.
• Processes phone calls related to the referral program. Assists in the education and problem-solving with both members and providers.
2..Is available as a consultant/resource for all non-medical personnel in the department.
3.Continuously improves work skills and knowledge. Participates in employer-sponsored training and education programs. Participates in additional external training and education programs. Evaluates process and creates plans for improvement.
4.Performs other duties as requested.
5.Maintains and assures complete confidentiality in all aspects of job-related information.
Arkansas Blue Cross and Blue Shield
- 2 years ago - save job
In 2012, Arkansas Blue Cross was named one of central Arkansas’ “Top Work Places” by the Arkansas Democrat-Gazette and...