Provide utilization management services which promote quality, cost-effective outcomes by helping the Medicaid member populations achieve effective utilization of healthcare services. Incorporate the essential functions of professional case management concepts to enhance patients’ quality of life and maximize health plan benefits. These functions include, but are not limited to:
- Coordination and delivery of healthcare services
- Consideration of physical, psychological, and cultural factors
- Assessment of the patient’s specific health plan benefits and additional medical, community, or financial resources available
- Collect and assess patient information pertinent to patient’s history, condition, and functional abilities in order to develop a comprehensive, individualized care plan that promotes appropriate utilization, and cost-effective care and services.
- Perform concurrent review of patients admitted to hospitals. Maintain telephone contact with the hospital utilization review personnel to assure appropriateness of continued stay and level of care. Identify cases that require discharge planning, including transfer to skilled nursing facilities, rehabilitation centers, home health or hospice services.
- Review referral and preauthorization requests for appropriateness of care within clinical guidelines. Incorporate knowledge of mortality, morbidity, and established standards of practice associated with surgical procedures, pharmaceuticals, medical and behavioral health diagnoses.
- Identify catastrophic and/or high exposure cases, case management, behavioral health or utilization review issues, pertinent inquiries, problems, and decisions that may require review. Work with direct supervisor for reporting these cases.
- Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients.
Work Experience: Five years nursing experience with varied medical exposure and experience. Experience in case management, including cases that require rehabilitation, home health, and hospice treatment. Insurance industry experiencepreferred.
Education, Certificates, Licenses: Registered nurse with current unrestricted state License.
Knowledge: Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedures codes including ICD-10, DSM-IV, and CPT Codes, health insurance and State-mandated benefits. Thorough knowledge and understanding of contractual benefits and options available outside contractual benefits. Thorough knowledge of community services, providers, vendors and facilities available to assist members. Thorough knowledge of creating appropriate case management plans. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision.
Job ID 2017-411