Location Address:Compensation Pay Range:Minimum Offer $65,520.00Maximum Offer $111,612.80
Summary:Applies Case Management principals in coordinating patient care across the continuum using assessment, care planning, implementation, coordination, monitoring and evaluation for cost effective and quality outcomes in a primarily inpatient setting, including complex discharge planning.
Performs Utilization Management clinical review to ensure that services rendered to members meet clinical criteria and are delivered in the appropriate setting. Utilizes clinical skills and knowledge to coordinate, document and communicate all aspects of the utilization/benefit management program. Performs care review both prospectively and retrospectively. Prospective review includes pre-service and concurrent services and procedures. Validates and interprets medical documentation using evidence-based criteria sets. Consults with PHP medical directors and refers for medical director decision on cases not meeting clinical criteria. Identifies members with complex conditions requiring one on one case management and/or disease management services and refers appropriately to the Presbyterian Integrated Care Management program.
Responsibilities:- Receives, reviews, verifies and processes requests for approval of pre-service and concurrent services including verification of eligibility and availability of benefits.
- Identifies and advocates for members in caseload, referring to appropriate inpatient, outpatient and community resources including care coordination.
- Conducts an in-depth assessment which includes, psychosocial, physical, medical, environmental and financial parameters. Collaborates with Healthcare team to proactively develop, implement and document treatment and discharge plan with appropriate resources to address social, physical, mental, emotional, spiritual and supportive needs.
- Collaboratively formulates, implements, coordinates, monitors, and evaluates strategies with the healthcare team to address care management issues for specific patients and disease processes
- Applies utilization review criteria to assess and document the appropriateness of admission, continued stay, level of care, and readiness for discharge; refers cases that do not meet criteria to designated Physician Advisor. Promotes the appropriate use of clinical and financial resources in order to improve quality of care and patient/member satisfaction.
- Advises manager/supervisor of possible trends in inappropriate utilization (under and/or over), and other quality of care issues.
- Communicates effectively with providers, PHP medical directors, Members, PHP departments as evaluated by supervisory audits
- Educates providers and other PHS/PHP departments on health management strategies and care coordination services
- Meets departmental and/or regulatory turnaround times for prior authorizations and concurrent reviews while maintaining productivity and quality standards.
- Performs other functions as required.
Qualifications:- Bachelors degree in Nursing, Business, or Health related field preferred. RN license required.
- Five years of experience in relevant clinical nursing.
- Requires a minimum of two years of recent pertinent experience in clinical adult inpatient setting, or NICU for NICU team, or ICU, or Medical Surgical Hospital clinical nursing and utilization review or case management within the last 10 years.
- National certification in Case Management preferred within 3 years of hire.
- Computer knowledge to include Windows, Word, Excel, and database systems.
- Ability to analyze trends based on decision support systems.
- Knowledge in referral coordination to community & private/public resources.
- Good organizational and time management skills.
- Ability to articulate orally and in writing an understanding of complex issues and action plans, while best representing the organization professionally.
- Ability to work cooperatively with other employees and departments.
- Efficient and comfortable with computer electronic data entry and documentation.
- Ability to succinctly document using correct spelling and grammar. Able to summarize from medical clinical notes.
- Ability to assertively and professionally interact with providers and compassionately assist members.
- Demonstrate critical thinking skills as evidenced by experience, education and/or the pre-hire interview process.
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