Supports the department’s quality of care and cost containment. Provides utilization management as needed to ensure coordination of health care delivery. Conducts medical appropriateness evaluations of hospital admissions and selected out patient procedures. Facilitates the achievement of quality clinical outcomes by integrated and collaborative interventions with multiple disciplines, Pre/Post Service. Ensures that members are receiving the appropriate level of care in the appropriate setting for the appropriate length of time within the established guidelines and benefit sets; Pre-service, Concurrent Review, Post Acute and Care Management. Work with interdisciplinary team to utilize the SNP members' Plan of care to achieve improved health outcomes.
- Utilizes InterQual Criteria, CMS Guidelines, medical and administrative policies to evaluate medical necessity.
- Identifies members at risk and refers for Care management and/or disease management as needed. Assesses and evaluates member’s needs, coordinate care utilizing approved criteria(s). Includes member and family discussion as necessary.
- Maintains utilization time frames are met according to regulatory guidelines (i.e., initial determination decisions, adverse determination notification to providers and members). Provides case review (when necessary) and assures timely notification and correspondence to facilities, members and providers.
- Utilizes the member’s contract to determine coverage eligibility. Works with providers and takes action in problem solving while exhibiting judgment and a realistic understanding of the issues.
- Prepares and presents clinical detail to the Medical Director for final case determination in accordance with regulation and department policy.
- Ensures cost effectiveness and identifies opportunities to reduce cost are captured (i.e. reinsurance reporting).
- Refers to Medical Director any questionable quality issues or inappropriate hospitalizations for immediate intervention and/or refer cases that do not meet established criteria for approval of selected procedure or service.
- Regular attendance is an essential function of the job. Performs other duties as assigned or required.
- RN, LPN, PA with two to four years of college with an active, unrestricted license or certification
- Minimum of three to five years of clinical experience
- Managed care experience preferred
- Care management experience desirable
- Excellent written and oral communication skills
- Effectively able to screen and stratify members who are appropriate for care management services
- Able to manage a caseload of members who are in need of care management and ability to apply the care management process as outlined by the CMSA standards and EH’s policies
- Makes appropriate referrals to internal and external programs that meet the member’s needs
- Ability to create and execute care management care plans and document per EH’s policies and procedures
- Ability to speak professionally with all necessary parties associated with the member’s care plan
- Requisition ID: 2013R