Job Description

Job Description

Job Description

Responsible to conduct systematic admission, concurrent and retrospective hospital reviews for severity of illness and length of stay, implements discharge planning, and to manage an inpatient authorization with required data and pertinent clinical information with intervention and follow-up

and/or

Coordinates and integrates through review, all services that require pre-authorization including all new technology and experimental/investigation services using the clinical review algorithm.

and/or

Responsible for the navigation and advocacy of identified members. These members require coordinated care and integration. This may include navigation beyond the specific case or situation, providing the member with a wide spectrum of services directed at not only medical or behavioral changes but healthy lifestyles and optimal outcomes assuring quality and continuity within the managed care system

and/or

Responsible for those identified members normally on a short term, episodic or situational basis, or those members with a life altering illness or injury including transition of care.

Required:

1. Registered Nurse with at least five (5) years experience. Two (2) of those years may be work experience as a nurse's aide, LPN or other appropriate position in a clinical setting. Preferred critical care or other acute care experience. (RN outside minimum experience may be waived for internal applicants currently employed as an LPN, applying for a THP RN position with demonstration of RN licensure and documented expertise in THP care coordination processes and with the written recommendation of current supervisor/manager.)
2. Active Ohio and WV licensure which must be maintained throughout employment, including compliance with State Boards of Nursing continuing education policy. Other licensure as company expansion warrants.

Desired:

1. Any Registered Nurse with a combination of academic education, professional training or work experience which demonstrates the ability to perform the duties of the position would be considered. Utilization Management, Quality Improvement, Case Management, Disease Management or other Managed Care experience would be helpful.
2. Should possess excellent oral, written, telephonic and interpersonal skills, balancing an independent and team working environment.
3. Should be flexible and able to multi-task, work in a fast-paced environment and adapt to changing processes.
4. Should possess a superior work ethic and a commitment to Excellence and Accountability.
5. Should possess ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues.
6. Should possess proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems.
7. Should possess ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues.
8. Managed care experience, utilization management experience/familiarity with Interqual or MCG or case management experience with a payor organization.
9. Certification in area of clinical expertise related to current work i.e. CDE, CCM, CMCN, Motivational Interviewing/MI Trainer, etc.

Responsibilities:

1. Conducts telephonic and/or on-site admission, concurrent or retrospective review of all inpatient admissions and observation stays.
2. Enters data timely and updates principle/secondary diagnoses and procedures, medical histories, and consults.
3. Investigates missed admissions obtaining pertinent details and refers to the Medical Director as appropriate with completion of documentation and follow up.
4. Determines appropriateness of admission and continued stay using established clinical criteria.
5. Refers admissions/continued stays with questionable medical necessity to the Medical Director with completion of documentation and follow-up.
6. Coordinates care in collaboration with the member, family, health care team members, hospital utilization review, social workers, and other resources to intervene proactively to identify needed medical services, utilization and discharge issues, modifiable risk factors, educational needs and available resources to affect individual health care outcomes positively.
7. Identifies members requiring discharge planning and facilitates interventions to coordinate care and services.
8. Identifies members that may need chronic disease navigation, complex case navigation, social service intervention and refers appropriately.
9. Acts as a liaison between member, provider and The Health Plan.
10. Collaborates and shares knowledge and expertise with peers, supervisors and other staff.
11. Serves as assigned on departmental or company committees and attends departmental or work-group meetings as scheduled.
12. Promotes communication, both internally and externally, to enhance effectiveness of medical management services.
13. Identifies opportunities for improvement in systems, processes, functions, programs, procedures and makes recommendations to the appropriate management staff.
14. Prioritizes assignments appropriately and maintains flexibility as new priorities arise.
15. Identifies potential quality issues, variances, hospital acquired conditions and never events and refers to QI Department.
16. Identifies requests for new technology and communicates that data to the medical policy director.
17. Takes after-hours and weekend call on rotation as assigned (volunteer only)
18. Strives to improve quality in all areas of responsibility and cooperates with all departments to improve quality through The Health Plan
19. Determines appropriateness of pre-authorizations using established clinical criteria and/or guidelines.
20. Reviews and evaluates relevant information including member history, medical records, group contracts, benefit design, plan limitations, exclusions, coordination of benefits and member eligibility in making decisions and recommendations that are consistent with sound medical and managed care practice.
21. Facilitates access to care, provides liaison services, advocates for, and educates members as needed.
22. Educates providers when indicated.
23. Promotes communication, both internally and externally, to enhance effectiveness of clinical services.
24. Develops and implements personalized care plans and uses specific assessment tools and revises these accordingly.
25. Reinforces appropriate self-care teaching and monitoring and provides up-to-date medical or behavioral health care information to help facilitate the members understanding of his/her options.
26. Helps member actively and knowledgably participate with their provider in their own health care decision-making.
27. Identifies and reports potential high cost cases to the reinsurance or stop loss carrier through hospital review, referral requests, care or complex case navigation or claims cost reports.
28. Utilizes clinical skills to assess, plan, implement, coordinate, monitor and evaluate each individual case, including those members identified by, but not limited to, Pharmacy Reporting, Depression Screening, Health Risk Assessments and screeners, readmission assessments and iPro risk data and reporting.
29. Provide telephonic guidance and support to members, physicians and other health care providers to facilitate the best options to meet an indivdual's health care needs.
30. Contact and engage member participation in the appropriate chronic disease navigation program.
31. Assess and stratify on the appropriate intervention level and assess and monitor member status through scheduled outbound calls and inbound calls.
32. Utilize critical thinking skills to manage and evaluate member status and current treatment regime against evidence-based guidelines.
33. Complete outreach in a timely and effective manner according to protocols and make adjustments to frequency and types of contacts to meet program goals.
34. Facilitate proactive interventions to include the application of appropriate therapies and systematic surveillance of appropriateness of medication, education and counseling about daily self management and symptom management.
35. Perform screenings and assessments of potential chronic disease navigation cases.
36. Demonstrate a working knowledge and adherence to contractual guidelines and policies of The Health Plan.
37. Assist in the development, implementation, and coordination of new and ongoing chronic disease navigation programs and projects.
38. Achieve optimal clinical and quality outcomes by effectively managing care and resources.
39. Participate in quality improvement activities to achieve program outcomes.

Equal Opportunity Employer

The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.

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