Performs utilization and case management functions in the acute care setting. Works to ensure quality care and appropriate utilization of services. Coordinates and collaborates with interdisciplinary team in the discharge planning process and manages all transitions of care. Identifies appropriate resources both internal and external required for a successful care management. Seeks out opportunities for alternative level of care.
Role & Responsibility
Ensures the member is at the appropriate level of care, in the appropriate setting, at the appropriate time through thorough utilization review. Utilizes evidence-based guidelines (Interqual) and collaborates with hospital case managers, social workers, Primary Care Physicians, attending physicians, internal team and Cigna- HealthSpring medical directors on a daily basis. Manages all transitions of care related to a hospital stay through patient interviews, effective planning, and collaboration with facility personnel and Cigna-HealthSpring teams to prevent unplanned transitions and readmissions through proven interventions. Knowledgeable about member benefits and assists member to maximize their individual benefit plan.
Facilitates authorizations for post-acute care services or medications. Reviews cases for quality of care concerns. Maintains strong working relationship with internal and external customers and communicates professionally. Documents authorizations and case management activities in software applications. Assumes leadership role in POD/IPA related meetings and shares knowledge and information. Interacts with local Network Administrator or POD/IPA medical director and physicians. Participates in process improvement activities and all STAR-related initiatives. May serve as a preceptor for new employees.
Minimum Requirements: Current state licensure as a Registered Nurse (RN), ASN. At least 5 years acute care clinical experience.
Preferred Requirements: BSN, Utilization review experience, knowledge of ICD and CPT coding, McKesson Interqual Criteria, managed care experience.