Clinical Management Nurse

US-RI-Smithfield
Req No.
2017-7303
Department
Medical Mgmt Utilization Mgmt
Type
Regular Full-Time
Category
Medical/Health

Overview

This position works collaboratively with the health care team to determine appropriateness of medical services, procedures and care setting for members by reviewing and evaluating medical information and individual needs and applying established national criteria and plan guidelines in order to ensure quality, cost effective care, and the transition of care from the acute setting.

Responsibilities

  • Performs pre-certification, concurrent and retrospective review of out-patient and in-patient services, including onsite at various contracted hospitals and/or telephonic using established criteria, plan benefit guidelines, and clinical judgment to determine appropriateness of medical services, procedures and care setting
  • Refers and discusses complex case or cases that do not meet established criteria and guidelines with the Physician Advisor
  • Communicates in appropriate manner, as identified by UM department, with hospital staff, including but not limited to, Physicians, Case Managers, and Rehabilitation Therapists, to ensure timely discharge planning and placement in most appropriate setting
  • Ensures that all company policies relative to privacy and confidentiality are followed and that any information either obtained or disclosed is done in confidence.
  • Performs on-site visits to members while hospitalized, as needed to facilitate enrollment into a Case Management or Transitions of Care program
  • Evaluates requests for outpatient services such as home care, therapies and DME and makes authorization decisions based on medical necessity, benefit coverage, and the ongoing needs of the individual member
  • Reviews requests for conditional benefits and utilizes established company clinical guidelines to determine medical necessity. Presents to Physician Advisor for authorization decision, as necessary
  • Identifies high-risk members and initiates appropriate referrals to case management. Alerts appropriate departments of possible primary or secondary insurance coverage.
  • Supports the referrals to case management of complex cases through use of the case management software system
  • Collaborates with peers internally and externally to continually ensure member’s health care needs are being met in accordance with the benefit plans and through identification of agreed upon alternative services.
  • Documents cost savings that may result from medical review process (i.e. bed downgrades, change to observation status, alternative setting, etc.)
  • Communicates with ancillary departments, as necessary, to meet individual needs of members and providers
  • Meets department and regulatory standards for accuracy, proficiency and documentation in order to communicate decisions and plan of care in an appropriate and timely manner, and to ensure appropriate reimbursement in the Claims adjudication system
  • Utilizes the case management software system to document any outreach activities associated with member enrollment in the Transitions of Care program, including educating members on how to better self manage their condition in both an acute or chronic stage including transitioning from hospital to home
  • Takes responsibility for professional development, supports a learning environment, and meets professional competency requirements
  • Attends all required  training sessions
  • Is proficient in all systems as required by department
  • Ensures that he/she can accomplish all required job responsibilities and tasks from his/her home/off-site work location. He/she also is responsible for acquiring all material necessary to ensure that he/she can completely accomplish all normal work requirements. If required, the equipment used must meet the company’s specifications and requirements (i.e., computer equipment that will be connected to the company’s LAN, etc.).   If this cannot be achieved, the employee will be expected to work on site.
  • Accomplishes assignments and gets work-load based on guidance from his/her management team. Assignments are subject to change, dependent on departmental needs
  • Participates in department continuous quality improvement activities
  • Attends all management-identified meetings in person. In rare circumstances, the employee may be allowed to conference in, at the discretion of the management team
  • Other duties as assigned
  • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Qualifications

Required: 

  • Registered Nurse with an active, current, unrestricted license in Rhode Island in good standing
  • Three (3) years’ experience in acute care or home care setting
  • Willing/excited to work in a fast-paced, but sometimes intense, rapidly expanding company
  • Comfortable working in a professional, diverse corporate setting
  • Maintains appropriate written and oral communication and documents member encounters and updates the system within established time frames
  • Demonstrated ability to effectively prioritize and execute tasks in a high-pressure environment and meet contractual timelines
  • Strong communication skills (written/verbal)
  • Good working knowledge of regulatory requirements/standards
  • Must exhibit a high level of professionalism and integrity
  • Adherence to all confidentiality regulations and agreements
  • Ability to travel for work, must have access to reliable transportation, valid driver’s license and proof of insurance
  • Intermediate skills in Microsoft Office (Word, Excel, Outlook)
  • Strong organizational and documentation skills
  • Excellent customer service orientation and interpersonal skills


Preferred:

  • Bachelor’s Degree
  • Medical/Utilization review experience
  • Case management experience
  • Experience working with the needs of individuals with behavioral health and/or long term care needs
  • Utilization review or case management certification
  • Bilingual (English/Spanish)

Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.

 

Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org

 

Neighborhood is an EOE M/F/D/V and an E-Verify Employer

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