Clinical Navigator (Remote)

CareFirst•Baltimore, MD

2d•Remote

About The Position

The Clinical Navigator (RN) is responsible for utilization management and concurrent review of inpatient care to ensure members receive medically necessary services at the appropriate level of care. Using MCG guidelines and clinical judgment, the Clinical Navigator evaluates medical necessity, supports discharge planning, and coordinates transitions of care. The role partners with hospitals, case managers, social workers, discharge planners, members, and families to promote timely, safe, and efficient movement to the next appropriate level of care while addressing barriers to discharge and optimizing healthcare outcomes. The candidate may also be required to come to the CareFirst office location periodically for meetings, training, or other business-related activities. The candidate's primary residence must be within the greater Baltimore metropolitan area. The ideal candidate will have previous experience with utilization management in a health care payor organization. Bilingual - fluent in Spanish a big plus!

Requirements

Bachelor's Degree in Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
RN - Registered Nurse in MD, VA or Washington, DC
5 years' clinically related experience working in Utilization Review, Care Management, and/or Home Health including Discharge Coordination
Strong interpersonal skills and the ability to engage in a member facing environment telephonically) while at the same time building relationships and partnerships with hospital care team and alternative care delivery partners to meeting member/enrollee needs.
Strong clinical documentation skills along with the ability to type on a computer keyboard with ease and speed.
Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and Power Point.
Strong analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis.
Knowledge of clinical standards of care and disease process and national, evidence based clinical guidelines and hospital operations.
Knowledge of available community resources and programs.
Basic understanding of the strategic and financial goals of a health care system, payer organization, health plan and/or health insurance operations (e.g. networks, eligibility, benefits).
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Must be eligible to work in the U.S. without Sponsorship

Nice To Haves

Previous experience performing utilization review in a payor organization.
Knowledge and experience with MCG
MCG certification
Experience working with Commercial and Federal Employee Program employee group member and Medicare/Medicaid enrollees and benefits contracts
Bilingual - fluent in Spanish

Responsibilities

Utilize clinical expertise and critical thinking skills to analyze available clinical information, Electronic Medical Records (EMRs), benefit contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements to aid in determination of appropriateness and authorization of inpatient clinical services.
Engages telephonically with member, family and providers to identify key strategic interventions, discharge planning and coordination to address members medical, behavioral and/or social determinant of health needs to promote a safe transition to the appropriate level of care and/or home.
Collaborates with CareFirst medical directors and participates in internal case rounds/discussions to determine appropriate course of action and level of care.
Applies sound clinical knowledge and judgment throughout the review process.
Follows member benefit contracts to assist with benefit determination.
Makes referrals to other care management programs as appropriate for chronic, long-term care coordination.
Works collaboratively with hospital teams to develop positive working relationships to decrease provider abrasion and improve the member experience.