Managed Care Nurse

Western & Southern Financial Group•Cincinnati, OH

1d•Onsite

About The Position

Provides concurrent and retrospective utilization reviews, large case management, disability case management, and other programs to improve the quality of medical care and control costs. Works with minimal supervision, makes decisions within an established range, escalates issues when necessary, and regularly updates the manager. The role works in an office setting and requires sustained computer work, communication with customers and associates, and preparation of written correspondence and reports. Extended hours may be required during peak workloads or special projects or events. Travel is not required.

Requirements

Bachelor's degree in Nursing (required).
Proven ability to handle multiple duties and complete assigned tasks accurately and on time; provide examples of working independently to schedule and initiate reviews and work with patients, providers, and claim processors (required).
Demonstrated working knowledge of medical technology, healthcare resources, and contemporary trends in healthcare delivery (required).
Excellent verbal and written communication skills, with the ability to communicate clearly, concisely, and effectively with administration, healthcare providers, and members; examples of written work such as correspondence or reports are expected (required).
Strong customer focus and ability to maintain a positive attitude (required).
Complete discretion in handling confidential and sensitive materials (required).
Registered Nurse state licensure and/or compact state licensure; must be a registered nurse in Ohio upon hire (required).
Ability to work in an office setting and remain stationary for extended periods while working at a desk, on a computer, with standard office equipment, or in meetings.
Ability to verbally communicate and exchange accurate information with customers and associates regularly.
Visual acuity to read and interpret correspondence, procedures, reports, and forms in paper and electronic formats, including inspection involving small defects or parts and use of measurement devices; visual acuity is also needed to assess accuracy, neatness, and thoroughness of work.
Ability to prepare written correspondence, reports, and forms using prescribed formats and appropriate punctuation, grammar, diction, and style.
Ability to apply logical thinking to define problems, collect data, establish facts, and draw valid conclusions.
Ability to perform substantial continuous movement of the wrists, hands, and fingers for computer work.
Extended hours may be required during peak workloads or special projects or events.

Nice To Haves

Working knowledge of utilization management principles, including use of physician consultants; preadmission and concurrent review; discharge planning; second opinions; catastrophic case-management programs; ACD telephone systems; and data collection, analysis, and reporting (preferred).
Familiarity with major criteria sets and length-of-stay guidelines used by most systems (preferred).
Working knowledge of ICD-10 codes (preferred).
Familiarity with ICD10-CM and CPT-4 coding and DRG-based systems (preferred).
Proficiency in Microsoft Office products (preferred).
Case/claim management system experience (preferred).

Responsibilities

Use clinical experience, clinical criteria and guidelines, and Plan provisions to monitor, evaluate, and coordinate inpatient and outpatient medical care for quality outcomes and reasonable costs.
Perform prospective and concurrent utilization reviews to assess medical necessity for inpatient admissions, continued inpatient stays, and selected outpatient services, supporting appropriate, high-quality, cost-effective care and efficient use of third-party services.
Help members (associates, retirees, and dependents) navigate healthcare and optimize benefit plan use by identifying opportunities to promote quality healthcare.
Monitor potential high-cost claims for early case-management intervention and conduct retrospective reviews to assess appropriateness and cost effectiveness.
Communicate regularly with members, physicians, physician office staff, pharmacists, and hospital utilization personnel.
Conduct and coordinate case management for non-occupational Short-Term Disability, return-to-work, and Family Medical Leave Act cases.
Keep management and internal physician consultants informed about the status of large case-management cases, and collaborate with them case by case.
Serve as a source of medical information for the Benefits Department.
Keep current with medical trends by reviewing journals and professional publications and attending seminars.
Document individual cases for cost-savings and efficiency analyses and as a legal record.
Comply with applicable federal and state laws, including HIPAA, regarding privacy, security, confidentiality, and protection of personal health information and personally identifiable information.
Provide support as needed for the Company's occupational nurse and wellness programs.
Perform other duties as assigned and comply with all policies and standards.