Care Mgmt Referral Analyst RN

Florida Blue • United States,

11d • Onsite

About The Position

The RN Referral Analyst position works in conjunction with and in support of the case management (CM) team, and assures the appropriate use of case management resources to accomplish the optimal quality outcomes. This determination includes level of care, discharge status, benefit analysis and needs of the Client as applicable. The RN Referral Analyst participates in ongoing departmental improvement, quality initiatives, and supports the strategic goals of Care Management.

Requirements

• 5+ years related work experience with a professional background in clinical nursing and patient assessment.
• Related BSN degree or additional related equivalent work experience
• Graduate of an accredited school of nursing
• RN - Registered Nurse - State Licensure
• ICU experience with higher-acuity patients in a clinical setting. 10+ years of extensive experience in various medical-surgical units will be considered, in substitute.
• Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices.
• Ability to collaborate with cross-operational areas within the organization.

Nice To Haves

• (CCM) Certified Case Manager
• Compact State Licensure in good standing.
• Prior experience in utilization management or case management preferred, preferably within the managed care environment
• Intensive care or higher-acuity patient experience preferred.
• Knowledge of managed care in a self-funded employer population is preferred.

Responsibilities

• Monitor and review referrals received from Utilization Management authorization triggers, high-dollar claimant reports, emergency room utilization reports and internal referrals from other care management departments and any departments that handle case management workflow.
• Assesses and assigns cases for medical case management based on acuity, staffing levels and clinical information available.
• Review clinical information supplied in UM authorizations, claims data/activity as part of the assessment process.
• Ensures additional documentation is uploaded to the case should documents and/or information need to be attached to a cases that is being referred.
• If a referral is not appropriate to fully open for Case Management, but the referred member could benefit from an alternate outreach campaign or initiative, the Referral Analyst will assist with identification of alternate care outreach plans for that member.
• These alternate plans will be based on plan/group resources (e.g. MES outreach around a specific concern).

Benefits

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, Short- and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan includes employer contribution and employer match
• Paid time off, volunteer time off, and 11 holidays
• Additional voluntary benefits available and a comprehensive wellness program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level