Health Net, Inc. is a publicly traded managed care organization that delivers managed health care services through health plans and government-sponsored managed care plans. Its mission is to help people be healthy, secure and comfortable. Health Net, through its subsidiaries, provides and administers health benefits to approximately 5.4 million individuals across the country through group, individual, Medicare (including the Medicare prescription drug benefit commonly referred to as "Part D"), Medicaid, U.S. Department of Defense, including TRICARE, and Veterans Affairs programs. Health Net's behavioral health services subsidiary, Managed Health Network, Inc., provides behavioral health, substance abuse and employee assistance programs to approximately 4.9 million individuals, including Health Net's own health plan members. Health Net's subsidiaries also offer managed health care products related to prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-funded benefits programs.
For more information on Health Net, Inc., please visit the company's website at
The position performs advanced and complicated case review and first level determination approvals for members receiving care in an inpatient setting determining the appropriateness and medical necessity of continuing inpatient confinement including appropriate level of care, intensity of service, length of stay and place of service.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Conducts advanced/complicated clinical case review for members receiving care in an inpatient setting. Determines the appropriateness and medical necessity of continuing inpatient confinement using clinical judgment, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans.
Reviews, triages and prioritizes cases to meet turnaround times. Expedites access to care for members with urgent or immediate needs using expedited review process.
Performs research and analyzes complex issues, assess member needs.
Identifies appropriate health care resources based on member's medical needs.
Performs discharge planning, care coordination, and authorization activities to assure appropriate post-hospital support and care.
Makes first level approval determinations when request meets appropriateness, medical necessity and benefit criteria.
Develops determination recommendations and presents cases to Medical Director for potential denial determinations or when input is needed. Refers potentially inappropriate admissions and days not meeting medical necessity criteria to Medical Directors.
Develops and/or reviews documentation and correspondence reflecting determination.
Identifies and refers members who may benefit from disease or case management and makes appropriate referrals.
Identifies potential reinsurance cases and notifies the appropriate department according to policy and procedure.
Identifies potential TPL/COB cases, investigate TPL/COB issues and notifies the appropriate departments.
Conducts rate negotiation, when necessary and per policy, with non-network providers, utilizing appropriate reimbursement methodologies.
Manages out of area cases/requests.
Works with delegated or contracted providers, groups or entities to assure effective and efficient delivery of services meeting goals.
Assesses contracted provider, provider group and/or facility performance levels against goals.
In conjunction with Medical Director, designs, initiates and implements participating group/ hospital strategies and interventions based on performance data.
Conducts hospital and/or provider group clinical operations assessments and evaluates effectiveness of clinical processes and practices to achieve optimum levels of performance.
Participates in departmental evaluation, audit and improvement activities.
Analyzes reports for quality of care, efficiency of services, cost effectiveness and reports quality outcomes.
Leads, facilitates and participates on committees.
Identifies systemic failures resulting in re-work, redundancy or reduced effectiveness.
Provides feedback to other departments regarding upstream failures and possible corrective action.
Graduate of an accredited nursing program.
Bachelor's degree preferred.
RN license; UM/CM certification preferred
Knowledge, Skills & Abilities:
- Minimum three years acute inpatient clinical experience required.
- Three to five years managed care experience, including discharge planning, Case Management, Utilization Management, transplant or related experience required.
- Health Plan experience preferred.
- Strong knowledge of NCQA, federal and state regulations/requirements.
- Demonstrated ability for assessment, evaluation and interpretation of medical information.
- Possess a high level of understanding of community resources, treatment options, home health, funding options and special programs.
- Strong analytical and problem solving skills required.
- Excellent verbal and written communications skills.
- Excellent case preparation and abstracting skills.
- Team player who builds effective working relationships.
- Ability to work independently.
- Experience using standardized clinical guidelines/criteria required.
- Strong organizational skills.
- Must be able to work well with all levels in the organization.
- Able to operate PC-based software programs including proficiency in Word, Excel, PowerPoint, Access and Project.
- Ability to effectively analyze, interpret, apply and communicate policies, procedures and regulations.
- Local travel required.
- May require current CPR certification and negative TB test.
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position
The following section describes the general physical requirements for this position. Please note that 'constant' refers to more than 81% of time; 'significant' refers to 40-80%; and 'moderate' refers to 20-40% of the time.
Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.
- Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.
- Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.
- May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).
- May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.
- Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.
- Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.
- Required to have hearing ability to receive detailed information through oral communication.
- Required to have speaking ability to express or exchange ideas.
- Constant concentration may be required on various subjects by listening, reading and thinking clearly.
- Interaction with others may be required.
- May need to listen, think, and speak in order to interact with others.
- Business interactions and behavior between coworkers and/or external customers are required. This may require face-to-face or telephone interactions.
- Thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next.
- Constant computer usage including typing and/or eye strain.
- Constant repetitive arm, wrist, hand and finger motions -- making repetitive movements (e.g. key boarding, filing, data entry).
- Constant phone usage; headsets may be required.
may be required between work sites and/or out of area.
- Constant sedentary work (desk bound or seated).
- Constant reading is required via computer screen and/or bound printed materials.
- Moderate walking/standing may be required.
- Walking and/or transporting supplies and equipment between buildings/parking lots and structures may be required.
Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.