Nurse Case Manager
Location: Helena Montana
Description: New West Health Services is at present recruited Nurse Case Manager right now, this position will be placed in Montana. Detailed specification about this position opportunity please give attention to these descriptions. Reports to: Medical Services Supervisor
FLSA Status Non Exempt
Effective Date: 4/2012
Summary
This position is a Nurse Case Manager responsible for coordinating healthcare and related services to members within the applicable benefit structure. Duties include evaluating inpatient and outpatient services within established medical criteria and operational policies and procedures to review appropriate levels of care, lengths of stay and discharge planning and to intervene when necessary to ensure appropriate and effective utilization and quality outcomes; serving in the roles of medical case manager for membership and as a leader for the medical services team; reviewing and making determinations regarding claims that require clinical and/or coding expertise for claims payment; and related duties. The Nurse Case Manager is expected to develop and maintain expertise in assigned specialties (mental health, Medicare, Obstetrics/Pediatrics, etc.) and/or specific facilities/providers.
Education, Certifications, Licenses and Experience
The position requires a current RN license to practice without restriction in the State of Montana plus five years prior nursing experience with preference given for care in these health care service areas: utilization review, oncology, obstetrics, pediatric, mental health, pharmacology, Medicare, or discharge planning. Certified in Healthcare Management (CPHM), Certified Case Manager (CCM), or Certified Professional in Healthcare Quality preferred (CPHQ).
Primary Duties and Responsibilities:
A. Utilization Management (55%)
Evaluates inpatient and outpatient requests for health care services within established medical criteria, and operational policies and procedures, to make determinations for coverage; reviews care to make determinations regarding appropriate levels of care and places of service, performs concurrent reviews and determines appropriate lengths of stay, and participates in discharge planning, intervening and coordinating with providers and members to ensure appropriate and effective utilization and quality outcomes. Nurse Case Manager_updated 4-2012
Reviews and evaluates proposed, current and retrospective requests for inpatient admissions and outpatient services, and for appropriate medical necessity, length of stay, and appropriate place of service. This involves researching medical criteria, policies and procedures; consulting with the Director of Medical Services and/or the Medical Director on medical necessity determinations; and initiating physician review of denials of benefit allocation for medical services when medical necessity and/or other established criteria are questionable.
Accurately inputs data for any type of health care service request and performs all inpatient medical and surgical utilization review requests in a timely manner according to department timelines and in conjunction with CMS requirements when applicable. Prioritizes daily activities through the use of daily utilization reports and processes health care service requests as assigned. Consistently demonstrates subject matter expertise and knowledge in a variety of clinical areas by using clinical resources to review new types of requests and to adequately prepare for concurrent reviews to ensure smooth provider interaction and education as needed. Smooth reviews are best accomplished via direct communication, and this position needs to have the confidence and organizational skills to request additional clinical information when needed and to strive to see the big picture regarding long-term needs for individual members.
Coordinates the review and processing of requests for services for out-of-state and/or out-of-network providers to ensure appropriate and cost-effective utilization and quality outcomes. This includes initiating authorization for out-of-network care when appropriate, redirecting members to in-network care as able and if appropriate, referring requests to the Medical Director with supporting documentation, and notifying Provider Services of approved requests to facilitate negotiations with facilities and providers, when needed.
Reports issues and collaborates with the Director of Clinical Operations or Medical Director, as needed, regarding requests for health care services that are complex or require direction or support for resolution (e.g., discharge planning, case management needs, pended claims, medical review, etc.). Ensures ongoing involvement in Utilization Management determinations and the referral of all complex cases to the Medical Director. Captures, tracks and reports data and outcomes associated with utilization management activities (e.g. why extension of days was authorized or a rate negotiated) to provide accurate records of utilization review activity.
Communicates with providers and members to notify them of denials from the Medical Director. This includes reviewing medical determinations, compiling the appropriate supporting documentation and justification, preparing letters and explanations, and answering questions.
Ensures benefit determinations are completed by the appropriate practitioner (e.g., that medical necessity denials are made by the Medical Director and behavioral health reviews are done by a behavioral health specialist) and that medical files and systems contain documentation of appropriate professional reviews and benefit determinations that are clear and specific as to reasons for denials. Ensure adequate documentation of professional review of all denials of health care services.
Consistently strives to improve processes and communicates ways to improve efficiency as needed. Examples include making recommendations on new systems and procedures, identifying non-participating healthcare providers to support adequate network coverage and communicating these opportunities to the Provider Relations Department for contracting considerations, taking the time to educate a provider on specific UR expectations for various disease conditions to improve the staff’s skill sets, etc.
Answers the department phone queue on a daily basis, as able, and functions as a back up to the Medical Services Specialist position, and other Nurse Care Managers, during times of reduced staffing or unforeseen increase in call activity and/or medical service utilization. Provides consistent and reliable office coverage through regular and timely attendance between 8:00 a.m. and 5:00 p.m. Monday through Friday.
Case Management & Leadership (35%)
Serves in the role of medical case manager for membership, and in a leadership role for the medical services team as an RN.
Manages the identification of high risk members and the development of plans of care to address the health care needs of members with high-risk conditions (e.g., heart disease, diabetes, cancer, spine injuries, etc.). This includes working with information technology systems to generate medical and claims data, evaluating this data to identify high risk members, making introductory contacts via phone and mail, initiating case management authorizations, referring members to case management and assessment specialists as appropriate, and documenting and communicating the estimated financial risk associated with these cases. When appropriate, notifies re-insurers and others of high-risk members and coordinates services and provides clinical updates, as appropriate.
Performs psychosocial and clinical assessments, of all assigned members, to identify high risk and/or chronic members to enroll into the Chronic Care Improvement Program (CCIP) and/or case management program services (Complex Oncology, Transplant, Readmission Prevention, etc.) as appropriate. This requires evaluation of enrollee conditions in relation to Evidence Based Care, National Case Management Standards, and, Medicare regulations, and applies to members for all NWHS lines of business and their associated benefit plans and coverage.
Maintains ongoing contact with members enrolled in case management. This includes considering member physical and psychosocial needs, creating individualized and thorough plans of care for mutually agreed-upon member goals, monitoring care plans, assessing member responses to treatments, revising and updating goals as needed, and providing assistance and education based on evidence based standards of care, as required and/or requested (i.e., assisting the member in communicating their needs to the healthcare team and in making informed decisions by ensuring they receive and understand appropriate information).
Communicates and collaborates with providers to ensure effective case management with member’s permission. This includes organizing facts, questions, and concerns to be discussed with providers, solving communication problems, and developing contingency plans for anticipated problems (i.e. sharing the hospitalist’s DC orders with the known behavorial health provider or medical specialist to ensure coordination of care).
Supports the Medical Services Supervisor in leading the Medical Services Department team, focusing on adequate staffing, coverage, and the facilitation of problem solving of day-to-day issues. This includes ensuring the consistent application of criteria, actively participating in staff training and development, role modeling high ethical standards and productivity levels, and monitoring documentation adequacy.
Accurately inputs data and performs case management assessments and interventions in a timely manner. Captures, tracks and reports data and outcomes associated with case management activities (e.g. how an intervention saved medical costs for the member) to provide accurate records of case management activity.
Participates in the development of case management programs as needed (e.g. as part of a task-oriented workgroup or as assigned) in an effort to strive for process improvement and/or program and project development. This may include performing research on CM activities and outcomes to ensure best practice, and lead to reporting project activities as needed to the Medical Services Supervisor and Department Director.
Collaborates with the Medical Services Supervisor, Director of Clinical Operations, the Medical Director, and other departments or business entities as needed to support Quality Assurance activities. This includes identifying and researching potential quality of care issues, working to resolve problems, and reporting concerns when reviewing care and pended claims to help ensure high quality health care for members.
Assists in developing, implementing, and evaluating educational materials for patients, families, and members as appropriate to ensure well-designed and effective educational material is evidence-based and used appropriately in educating members and that it meets CMS requirements and are consistent with national CM standards.
Claims Auditing and Pended Claims (8%)
Reviews and makes determinations regarding claims that require clinical and/or coding expertise for claims payment as assigned (e.g., provider appeals, non-covered services performed concurrently with covered services, unlisted codes, potentially-covered services, etc.).
Addresses pended claims requiring clinical and/or coding expertise to ensure claims are processed on a weekly basis to maintain a maximum claims age of 40 days by researching contact logs, authorizations, benefit plans, payments, and other claim activity; requesting and reviewing medical records as needed; referring information to the Medical Director or rendering a decision in cases where criteria are clear; and releasing claims for payment or denial. This may include communicating with providers and members, evaluating medical files and research performed by Medical Services Specialists, and evaluating a range of information including medical guidelines, managed care practices, ICD/CPT coding, length of stay guidelines, appropriate levels of care, modalities by diagnosis, etc.
Provides input to the Medical Services Supervisor regarding trends and possible adjustments to the adjudication policies for codes and claims received (e.g., the use of modifiers and code combinations), submits changes to the editing system using internal processes, and addresses other related medical and operational issues as a means of continuous process improvement.
Other Duties as Assigned (2%)
Performs a variety of other professional and administrative work as assigned by the Medical Services Supervisor, or the Director of Clinical Operations. Participates in the development Medical Services programs as needed (e.g. as part of a task-oriented workgroup or operational team) for process improvement and project development. This includes testing systems, making recommendations on new systems and procedures, and auditing authorization and department work processes for data entry accuracy, policy and procedure adherence, and consistent decision making; Coordinating special projects and events, attending training and continuing education, and providing backup and coverage for other Department staff as assigned.
The above statements are intended to describe the general nature and level of work being performed by employees in this position. They are not intended to be an exhaustive list of all duties, responsibilities, and qualifications of employees assigned to this job.
Work Conditions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit. The employee is frequently required to stand, walk, talk and hear including communicating effectively over the phone and in person. The employee must occasionally lift and/or move up to 25 pounds. Regular and timely attendance between 8:00 a.m. and 5:00 p.m. Monday through Friday is an essential requirement of the job. The noise level in the work environment is usually moderate.
Knowledge, Skills and Abilities
Knowledge:
The position requires an advanced knowledge of the principles and practices of nursing including medicine, biology, pharmacology, psychology, and medical terminology. The position requires knowledge of utilization management and review; CMS policy and requirements, knowledge of national case management standards, managed care and health insurance processes; understanding of medical referrals and claims processing; knowledge of levels of care, including acute and sub-acute care; home care; long-term care; and rehabilitation, along with options and alternatives for different levels of care, Detailed knowledge of medical necessity requirements; processes for quality assurance and determining positive outcomes; current standards, trends and best practices in health care; healthcare management tools and related resources and literature; case management techniques; customer relations and member outreach; pre-authorization functions; and cost containment, rate negotiation, and professional interdisciplinary coordination techniques.
Skills:
The position requires excellent interpersonal, communication, and leadership skills. The position requires skill in accurate data entry, keyboarding, operating computer programs efficiently, accurate grammar and spelling in communicating to customers, interpreting and applying medical, insurance, and State and Federal guidelines and policies to individual circumstances independently, to learn and apply knowledge of the health insurance industry, CMS regulations, and New West Health Services business processes to individual circumstances, and in the analysis and communication of complicated medical data and case management programs and careplan interventions.
Abilities:
The position requires the ability to talk on the phone with providers while simultaneously documenting decisions and researching data, to accurately describe benefit coverage determinations in a timely manner, to maintain high levels of quality care and customer satisfaction, to analyze complicated medical information and draw conclusions; work with providers and take action in problem solving while exhibiting judgment and a realistic understanding of the issues, to determine when to involve the Medical Director or Department Supervisor or Director, to be highly self-motivated, self-directed and willing to adapt and contribute in a team environment; to effectively prioritize and execute tasks under tight deadlines and manage a high volume of work; and to provide effective services to a variety of customers. This position requires the employee to maintain regular and timely attendance at work between the hours of 8a and 5p.
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If you were eligible to this position, please email us your resume, with salary requirements and a resume to New West Health Services.
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This position starts available on: Thu, 12 Jul 2012 13:15:18 GMT