JOB SUMMARYThis is a full-time hybrid work from home position requiring travel within the assigned territory. A portion of this role involves working directly with members where they are.
 

This job is proficient in the coordination of care and manages coordination of care in accordance with recognized standards of practice for Care Management. The incumbent utilizes expertise in care management to promote a collaborative professional environment that supports excellence of care and achievement of optimal resource utilization. Also facilitates appropriate LOS, patient satisfaction and reimbursement for all patients.

ESSENTIAL RESPONSIBILITIES

• Assumes role in assessment of patient physical, psychosocial, and economic needs for effective transition of care planning to a variety of levels of care.
• In collaboration with the care team, facilitates the development and communication of the continuum of care transition plan to appropriate health service providers.
• Documents, verifies, and validates specific data required to monitor and evaluate interventions and outcomes. Interviews and collects patient specified data and chart review related to readmission.
• Knowledgeable of and complies with accreditation and regulatory requirements. Integrates performance improvement principles and customer service principles into all aspects of job responsibilities.
• Obtains or ensures acquisition of appropriate pre-certification authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party guidelines. Obtains or facilitates acquisitions of urgent / emergent authorizations, continued stay authorizations and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements.
• Documents, monitors, intervenes/resolves and reports clinical denials/appeals and retrospective payer audit denials. Collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor and third party payers.
• Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental commercial payer guidelines. Adheres to the policies, procedures, rules, regulations and laws of the hospital and all federal and state regulatory bodies. Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
• Assumes responsibility for AHN required continued education and own professional growth.
• Other duties as assigned or requested.

EDUCATION

Required

• Bachelor's Degree in Nursing

Substitutions

• 6 years of related and progressive experience in lieu of Bachelor's degree

EXPERIENCE

Required

• 2 years of recent clinical RN Acute care, Home care, Palliative, Hospice, or Care Management

Preferred

• Home care, or Hospice, or Palliative care
• Discharge planning and community resource knowledge
• Care facilitation and utilization review experience

LICENSES or CERTIFICATIONS

Required

• Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

Preferred

• None

SKILLS

• Motivational interviewing competency
• Advance care planning competency
• Ability to work in a high performing team environment that requires flexibility
• Excellent organizational and time management skills. 
• Competent computer skills including Microsoft Office products

Language (Other than English):

None

Travel Requirement:

50% - 75%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Never

Exposure to blood, body fluids or tissue

Occasionally

Exposure to needles or sharps

Occasionally

Additional Employment Requirements:

• CPR Certification

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.