- Use industry criteria, benefit plan design, clinical knowledge, and critical thinking to assess, plan and provide, ongoing coordination and management of service delivery through an integrated case management approach with utilization review and case management activities.
- Identify and problem solve issues with appropriate services to ensure positive member outcomes utilizing cost efficient covered services.
- Provide an integrated holistic case management telephonic approach to those with chronic medical and behavioral health conditions with the goal of reducing the clinical gap between inpatient and outpatient services and potentially prevent hospital re-admissions.
- Authorize vendor services using clinically proven criteria to make consistent care decisions.
- Assist with discharge planning and care coordination to ensure optimal outcomes.
- Maintain accurate record of case management assessment and intervention including benefit/cost analysis for data collection and trending.
- Promote active involvement and initiative to members regarding their health care management and navigating health care delivery systems in order to preserve benefit resources.
- Communicate effectively with members, physicians, and providers. Facilitate, advocate, and educate on the disease process; be a liaison and provide referrals to other departments and programs as needed.
- Responsible for abiding by and supporting the care management programs in order to ensure quality and efficient clinical operations.
- Perform additional duties and projects as assigned by management.
- High School Diploma or GED required, college degree preferred; plus
- Valid New York State Registered Nurse (RN) required.
- Minimum two (2) years medical/surgical or behavioral health clinical experience plus a minimum of one (1) year case management utilization review experience required.
- Strong experience with discharge planning.
- Strong knowledge with standard utilization criteria (Milliman, Interqual), Medicare/Medicaid coverage guidelines, health claims processing, medical coding and interpreting provider contracts.
- Excellent verbal and written communication skills, problem-solving, clinical assessment/care planning skills, and independent decision-making capability.
- Computer and organizational skills required, ability to manage competing priorities, multi-task with results oriented outcomes and work in a fast paced environment.
- Must meet performance standards including attendance and punctuality.