Clinical Navigator (Remote)

CareFirst•Baltimore, MD

3d•Remote

About The Position

The Clinical Navigator (RN) conducts concurrent reviews of inpatient levels of care and manages timely, smooth transitions from inpatient care to home or other care settings. Using care management and utilization management experience, the navigator applies MCG criteria and considers administrative and regulatory requirements to assess medical necessity and appropriate levels of care, while engaging members, families, and support systems in discharge planning. The role works telephonically with hospital care teams—including case managers, social workers, and discharge planners—to help ensure members receive appropriate care and to address potential discharge barriers. The navigator may need to visit a CareFirst office periodically for meetings, training, or other business activities. Candidates must be located in Maryland, Washington, DC, or Northern Virginia. Spanish fluency is a plus.

Requirements

Bachelor's degree in Nursing, or an additional four years of relevant work experience in lieu of the degree.
Five years of clinically related experience in Care Management, Home Health, Discharge Coordination, and/or Utilization Review.
RN licensure in Maryland, Virginia, or Washington, DC, or compact state licensure.
Strong interpersonal skills and ability to engage members telephonically while building relationships with hospital care teams and alternative care delivery partners.
Strong clinical documentation skills and ability to type with ease and speed.
Proficiency with web-based technology and Microsoft Office applications, including Word, Excel, and PowerPoint.
Strong analytical and problem-solving skills to assess the appropriateness of member services and treatments on a case-by-case basis.
Knowledge of clinical standards of care, disease processes, evidence-based clinical guidelines, and hospital operations.
Knowledge of available community resources and programs.
Basic understanding of the strategic and financial goals of healthcare systems, payer organizations, health plans, and/or health insurance operations, including networks, eligibility, and benefits.
Must be eligible to work in the U.S. without sponsorship.
Must immediately disclose any debarment, exclusion, or other event that makes the incumbent ineligible to perform work directly or indirectly on Federal health care programs.

Nice To Haves

Fluency in Spanish.
Knowledge and experience with MCG.
Experience working with Commercial and Federal Employee Program (FEP) members and Medicare/Medicaid enrollees and benefit contracts.
CCM certification.
MCG certification.

Responsibilities

Analyze clinical information, electronic medical records, benefit contracts, mandates, medical policy, evidence-based research, and accreditation and regulatory requirements to support determinations of medical necessity and authorization of inpatient services.
Engage members, families, and providers by telephone to identify interventions and coordinate discharge planning that addresses medical, behavioral, and social determinant of health needs.
Promote safe transitions to the appropriate level of care or home.
Collaborate with CareFirst medical directors and participate in internal case rounds and discussions to determine an appropriate course of action and level of care.
Apply clinical knowledge and judgment throughout the review process.
Use member benefit contracts to assist with benefit determinations.
Refer members to other care management programs when appropriate for chronic or long-term care coordination.
Work collaboratively with hospital teams to build positive relationships, decrease provider abrasion, and improve the member experience.