Care Management Nurse
Highmark West Virginia - Charleston, WV

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Summary / Overall Purpose of Position:
The Care Manager holds a pivotal position in the Medical Management area by interacting with providers and members to implement effective utilization management strategies. The Care Manager reviews appropriateness of health care services; applies relevant clinical criteria which assures appropriate cost-effective resource utilization; identifies opportunities for Case Management and Disease Management initiatives; provides education to providers, members and other Plan employees; and identifies quality issues.

This position is responsible for the following functions:
1. Achieve effective utilization strategies by applying criteria to ensure medical necessity, appropriateness of setting, quality of care, length of stay or continuation of treatment and discharge planning.

2. Address medical, functional, social, environmental, cognitive and financial needs through communication with utilization review representatives, discharge planners, physicians, and others directly involved in members' care.

3. Analyze factors involved in providing the most appropriate care provider, assessing the variety of services provided, accreditation, accessibility, reputation, provider credentialing and participating contracts.

4. Resolve complex case reviews according to accepted and established criteria, medical policies and approved guidelines while assisting physician advisors, medical directors and managers in the development of strategies to facilitate optimal healthcare utilization and delivery.

5. Refer cases to appropriate personnel in Legal, Subrogation, Fraud, Finance, and Internal Auditing departments for follow-up on potential high cost, subrogation, fraud investigation or quality of care concerns.

6. Identify and refer targeted cases to Case Management and Disease Management.

7. Negotiate with vendors/providers to ensure that Highmark Blue Cross Blue Shield West Virginia is obtaining optimum pricing with regard to services, including the utilization of established networks and fee schedules.

8. Maintain current working knowledge of all Highmark West Virginia systems, including the managed care and claims inquiry systems, departmental policies and procedures as applicable to the Care Management process.

9. Participate as needed in forums for the discussion of health care utilization patterns.

10. Maintain individual quality and quantity standards as outlined in departmental policies and procedures while ensuring quality of care to members.

11. Ensure compliance with URAC and DOL as applicable to Care Management.

12. Provide provider and subscriber education regarding authorization processes and requirements.

Under the direction of the Manager of Medical Management the incumbent will:

1. Conduct initial clinical reviews for prospective, concurrent, and retrospective cases for appropriateness, maintaining compliance with Highmark West Virginia Health Services operational policies, DOL regulations, CMS (Center for Medicare and Medicaid Services) rules/regulations and URAC standards.

2. Assess medical necessity and appropriateness of care using nationally recognized evidence-based criteria and /or corporate medical policies including the evaluation of appropriate level of care for treatment including facilitating alternative levels of care as appropriate.

3. Respond to member inquiries and offer interventions and/or alternatives, and facilitate requests consistent with specific member and group requirements.

4. Identify potential coordination of benefits, high cost, subrogation, quality of care, worker's compensation and legal liability situations and refer such issues to the appropriate Plan departments.

5. Identify and refer cases that may benefit from case management/disease management and catastrophic/chronic cases to the Nurse Case Management Specialist and/or to the Disease Management Coordinator as appropriate.

6. Maintain compliance in accordance with URAC standards and with HIPAA (Health Insurance Portability and Accountability Act) regulations in regards to security and confidentiality with PHI (Private Health Information), and comply with all accrediting and regulatory standards including, but not limited to, DOL (Department of Labor) timeframes.

7. Facilitate discharge planning needs consistent with benefits, ensuring appropriate quality of care for the member.

8. Monitor and analyze delivery of health care services; educate providers and members on a proactive basis; analyze qualitative and quantitative data in developing strategies to improve provider performance and member satisfaction.

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