Resp & Qualifications PURPOSE: The Clinical Navigator (RN) is responsible for utilization management and concurrent review of inpatient care to ensure members receive medically necessary services at the appropriate level of care. Using MCG guidelines and clinical judgment, the Clinical Navigator evaluates medical necessity, supports discharge planning, and coordinates transitions of care. The role partners with hospitals, case managers, social workers, discharge planners, members, and families to promote timely, safe, and efficient movement to the next appropriate level of care while addressing barriers to discharge and optimizing healthcare outcomes. The candidate may also be required to come to the CareFirst office location periodically for meetings, training, or other business-related activities. The candidate's primary residence must be within the greater Baltimore metropolitan area. The ideal candidate will have previous experience with utilization management in a health care payor organization. Bilingual - fluent in Spanish a big plus!
ESSENTIAL FUNCTIONS:- Utilize clinical expertise and critical thinking skills to analyze available clinical information, Electronic Medical Records (EMRs), benefit contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements to aid in determination of appropriateness and authorization of inpatient clinical services. Engages telephonically with member, family and providers to identify key strategic interventions, discharge planning and coordination to address members medical, behavioral and/or social determinant of health needs to promote a safe transition to the appropriate level of care and/or home.
- Collaborates with CareFirst medical directors and participates in internal case rounds/discussions to determine appropriate course of action and level of care. Applies sound clinical knowledge and judgment throughout the review process. Follows member benefit contracts to assist with benefit determination.
- Makes referrals to other care management programs as appropriate for chronic, long-term care coordination.
- Works collaboratively with hospital teams to develop positive working relationships to decrease provider abrasion and improve the member experience.
QUALIFICATIONS:Education Level: Bachelor's Degree in Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Licenses/Certifications Upon Hire Required:- RN - Registered Nurse - State Licensure And/or Compact State Licensure: RN - Registered Nurse in MD, VA or Washington, DC
Experience: 5 years' clinically related experience working in Utilization Review, Care Management, and/or Home Health including Discharge Coordination
Preferred Qualifications:- Previous experience performing utilization review in a payor organization. Knowledge and experience with MCG
- Experience working with Commercial and Federal Employee Program employee group member and Medicare/Medicaid enrollees and benefits contracts
- MCG certification
Knowledge, Skills and Abilities (KSAs)- Strong interpersonal skills and the ability to engage in a member facing environment telephonically) while at the same time building relationships and partnerships with hospital care team and alternative care delivery partners to meeting member/enrollee needs.
- Strong clinical documentation skills along with the ability to type on a computer keyboard with ease and speed.
- Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and Power Point.
- Strong analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis.
- Knowledge of clinical standards of care and disease process and national, evidence based clinical guidelines and hospital operations.
- Knowledge of available community resources and programs.
- Basic understanding of the strategic and financial goals of a health care system, payer organization, health plan and/or health insurance operations (e.g. networks, eligibility, benefits).
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $72,360 - $143,715
Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
PHYSICAL DEMANDS:The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US Must be eligible to work in the U.S. without Sponsorship
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