Nurse Case Manager/Precertification Nurse
AmeriBen/IEC Group - Boise, ID

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DESCRIPTION

The Nurse Case Manager/Precertification Nurse will, in accordance with the Nursing Process, the Standards of Nursing Practice, and progression toward URAC standards, facilitate the appropriate health care services in the most cost effective manner to promote an optimal outcome without compromising quality of care. In addition, provide backup coverage for coordinating medical care requests based on medical necessity, using internal guidelines and criteria, nursing judgment and the specific requirements of pertinent group health plans.

DUTIES

Key Result Areas

  • Establish personal contact with patients and family members
  • Assess the patient's current status, prognosis, future care needs, treatment plan and alternative treatment plans
  • Conduct telephonic precertification services including prospective, concurrent and retrospective review using internal guidelines and criteria, nursing judgment and physician advisor review if needed.
  • Facilitate appropriate discharge planning
  • Assess the family dynamics and home environment and needs
  • Identify barriers to recovery
  • Maintain appropriate documentation of all cases and progression toward URAC standards
  • Develop and implement individualized Case Management plans
  • Evaluate effectiveness of care plan and progress made by patient
  • Work closely with providers to ensure appropriate utilization of services and effective cost management
  • Document findings and appropriate cost effective recommendations within identified timelines using URAC regulations
  • Capture and record any cost savings
  • Act as a liaison between referral source, family, employee, physician, facilities and providers, employer and internal and external stop loss
  • Maintain confidentiality of records and information
  • Maintain and report applicable statistics regarding programs and patient services
QUALIFICATIONS

Minimum Qualifications

  • Current Idaho R. N. license with 3 years of clinical experience and eligible to sit for the CCM certification exam
  • Certification in Utilization Management, Case Management or health Care Quality Management preferred
  • Knowledge of HIPAA and DOL regulations
  • Knowledge of CPT and ICD-9 codes
  • Type 45 words per minute and experience working in Microsoft Word, Excel and Power Point.
  • Strong interpersonal relationship skills and the ability to work effectively with a diverse patient population.
  • Ability to communicate effectively, both orally and in writing, medical information to health care professionals, employer groups, Brokers, stop loss personnel, internal customers, members and patient families
  • Ability to work independently
  • Time management, Organizational, Research, Analytical, and Records Maintenance skills
  • Negotiation skills
  • Ability to work efficiently, perform multi-tasking, prioritize tasks, and meet tight deadlines
  • Ability to efficiently and effectively perform the Essential Key Result Areas with or without a reasonable accommodation without posing a direct safety threat to others or self
Key Result Areas

  • Establish personal contact with patients and family members
  • Assess the patient's current status, prognosis, future care needs, treatment plan and alternative treatment plans
  • Conduct telephonic precertification services including prospective, concurrent and retrospective review using internal guidelines and criteria, nursing judgment and physician advisor review if needed.
  • Facilitate appropriate discharge planning
  • Assess the family dynamics and home environment and needs
  • Identify barriers to recovery
  • Maintain appropriate documentation of all cases and progression toward URAC standards
  • Develop and implement individualized Case Management plans
  • Evaluate effectiveness of care plan and progress made by patient
  • Work closely with providers to ensure appropriate utilization of services and effective cost management
  • Document findings and appropriate cost effective recommendations within identified timelines using URAC regulations
  • Capture and record any cost savings
  • Act as a liaison between referral source, family, employee, physician, facilities and providers, employer and internal and external stop loss
  • Maintain confidentiality of records and information
  • Maintain and report applicable statistics regarding programs and patient services

AmeriBen/IEC Group - 21 months ago - save job - copy to clipboard - block
About this company
Founded in 1964 AmeriBen Solutions is one of the oldest benefit administration organizations in the country. For over 35 years we have...