This position provides comprehensive care management services for self funded health benefit plans (ASO, Administrative Services Only), as established and directed by the Third Party Administrator (TPA), the individual employer group Summary Plan Description (SPD), the individual employer group's stoploss reinsurance carrier, Department of Labor (DOL) guidelines and any applicable specific state requirements. Comprehensive care management functions include Utilization (Use) Management, Case Management, Disease Management and Cost Containment, providing the continuum of health services necessary to improve health, prevent and control disease and have a measurable impact on health related costs. The incumbent will assist in containing the cost of health care services by detecting, resolving and preventing improper utilization of member benefits through precertification and concurrent review of medically necessary services. The incumbent will conduct triage of referrals from all sources using a systematic approach, clinical judgment and data analysis to identify members who would benefit from Case Management or Disease Management. This position will also assess, plan, implement and evaluate the options and services to meet an individual's health needs.
Primary Job Duties:
- Performs a complete review for medical necessity, pre service, post service, or concurrent, using criteria, medical policy and submitted medical information, with Medical Director review as indicated. The RN will complete the appropriate notification processes.
- Demonstrates the ability to triage incoming calls for urgency and comply with regulatory processes. Depending on the type of request, the RN must possess the knowledge of applying the appropriate timeframes to the request and meet those timeframes for requesting medical records or sending out the decision of the request. Along with the timeframes, when requesting records, the RN must demonstrate the ability to be compliant with HIPAA (Health Insurance Portability and Accountability Act) on the information being requested.
- Provides cost effective claim negotiation services with out-of-network (OON) providers for precertified medically necessary health services, in coordination with the TPA, and as per SPD plan provisions.
- Facilitates and provides adverse determination case appeal reviews as requested, and as appropriate, based on a member's appeal rights, SPD plan provisions and DOL guidelines.
- Acts as an advocate and liaison to meet a member's individual health care needs, the RN will assess, plan, implement, coordinate, monitor and evaluate options and services. This is accomplished by using communication and available resources to educate the member and to promote quality, cost-effective outcomes in accordance with available contract benefits.
- Exhibits and applies clinical understanding of the medical diagnosis (es), case and disease management processes, and psycho-social needs of members and their support system toward the development of an appropriate treatment plan in conjunction with the member's physician(s) and other pertinent allied health professionals. (15%)
- Identifies potential high cost claimants and potential stoploss claims, and provide appropriate disclosure notification as directed by the plan, the TPA and the stoploss carrier, as per the established communication processes.
- Performs other related duties as requires.
Bachelors Degree (N/A)
- Excellent time management skills with ability to multi-task
- Excellent organizational skills and attention to detail
- Excellent verbal and written communication skills
- Strategic thinking/planning/problem-solving skills
- Ability to work effectively with minor supervision, independently and with the team
- Must be able to work in a fast-paced environment with daily work processing deadlines
- High degree of business maturity and demonstrated confidentiality, HIPAA compliant
- High energy level and ability to project enthusiasm
- Persuasive communication style
- Polished, professional image and reputation
- Demonstrated personal accountability
- Excellent computer skills with ability to work in multiple software programs including MS Word, MS Excel, MS PowerPoint, MS Access, Visio
- Knowledge/experience in all aspects of care management and the health insurance industry
- Knowledge/experience in medical management of self funded (ASO) health plans
- Experience with claim review, ICD-9, CPT coding preferred
- Stoploss claim experience desired
CCM designation required within 3 years of accepting position. 3 years clinical experience, 1 year of which must be in a hospital setting. Multi-state RN licensure preferred. Bilingual ability preferred, fluent in Spanish.
Associates Degree (N/A)
3 years clinical experience, 1 year of which must be in a hospital setting. CCM designation required within 3 years of accepting position. Multi-state RN licensure preferred.
- Must be able to work in an office environment
- Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
- Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
- Registered Nurse
- Certified Case Manager
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