Reviews all inpatient admissions to assure appropriate level of care. Coordinates with physicians, staff, and facilities regarding patient care. In conjunction with and under the supervision of physicians, evaluates care plans and discharge plans, monitors all clinical activities, identifies alternative levels of care when requested care is not covered, identifies cost-effective protocols, and develops guidelines for coverage of benefits.
- Monitors all inpatient care provided to members. In conjunction with and under the supervision of physicians, evaluates and provides feedback to treating physicians regarding a member's discharge plans and available covered services including identifying alternative levels of care that may be covered.
- Coordinates, directs, and performs concurrent and retrospective reviews; monitors level and quality of care. Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
- Coordinates an interdisciplinary approach to support continuity of care. Identifies covered services, including utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for outside services for patients/families.
- Consults with physicians, health care providers, and outside agencies regarding continued care/treatment or hospitalization.
- Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum. Develops and collects data, and trends utilization of health care resources.
- Interprets health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies. Coordinates transmission of clinical and benefit treatment to patients, families and outside agencies. Makes referrals to appropriate community services.
- Responsible for the early identification and assessment of members for admittance to a comprehensive case management program.
- Actively participates in the discussion and notification processes that result from the medical record reviews with the facilities. Prepares notification letters of denied and negotiated days within the established time frames.
- Assists in the identification and reporting of potential quality improvement issues. Responsible for assuring these issues are reported to the Quality Improvement Department.
- Performs other duties as required.
- Registered nurse with active state RN license preferred.
- Significant (usually 3+ years) clinical experience.OR
- Licensed Practical Nurse with active state LPN license.
- Minimum 3 years clinical experience required, and
- Minimum 5 years managed care or equivalent experience.
- Bachelor’s degree preferred.
- Previous case management experience preferred.
- Demonstrated experience in utilization management, discharge planning, or transfer coordination.
- Valid driver’s license and a reliable personal vehicle for travel between work and hospitals is required.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Primary Location: Newark, DE, US
Other Locations: ,
Organization: 15000 - CHC of Delaware
Job Posting: 2013-05-20 00:00:00.0
Job ID: 1311803
In May of 2013, Coventry became a part of Aetna. We are excited to join together with common values and a common mission: empowering people...