Managed Care Nurse
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 uses clinical experience, clinical criteria and guidelines, and plan provisions to monitor, evaluate, and coordinate inpatient and outpatient care. It supports members in navigating healthcare and using benefit plans effectively, identifies potential high-cost claims for early intervention, and conducts case management for non-occupational Short-Term Disability, return-to-work, and Family Medical Leave Act cases. The nurse communicates with members and healthcare professionals, documents cases for cost and efficiency analysis and legal records, and supports occupational nursing and wellness programs. The position works in an office setting, with long periods at a desk or in meetings and continuous computer work. Extended hours may be required during peak workloads or special projects and events. No travel is required.
Requirements
- Bachelor's degree in Nursing.
- Proven ability to handle multiple duties and complete assigned tasks accurately and on time, including examples of working independently to schedule and initiate reviews and work with patients, providers, and claim processors.
- Strong knowledge of medical technology, healthcare resources, and contemporary trends in the healthcare delivery system.
- Excellent verbal and written communication skills, including the ability to communicate clearly and concisely with all levels of administration, healthcare providers, and members; examples of written work such as correspondence or reports are expected.
- High level of customer focus and ability to maintain a positive attitude.
- Complete discretion in handling confidential and sensitive materials.
- Registered nurse state licensure and/or compact state licensure; must be a registered nurse in Ohio upon hire.
Nice To Haves
- Working knowledge of utilization management principles, including use of physician consultants, preadmission review, concurrent review, discharge planning, second opinion, catastrophic case-management programs, ACD telephone systems, and data collection, analysis, and reporting.
- Familiarity with major criteria sets and length-of-stay guidelines used by most systems.
- Working knowledge of ICD-10 codes.
- Familiarity with ICD-10-CM and CPT-4 coding and DRG-based systems.
- Proficiency in Microsoft Office products.
- Case or claim management system experience.
Responsibilities
- Use clinical experience, clinical criteria and guidelines, and plan provisions to monitor, evaluate, and coordinate inpatient and outpatient medical care to promote quality outcomes at reasonable costs.
- Perform prospective and concurrent utilization reviews to determine medical necessity for inpatient admissions, continued inpatient stays, and selected outpatient services.
- Help members navigate healthcare and optimize benefit plan utilization 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 activities for non-occupational Short-Term Disability, return-to-work, and Family Medical Leave Act cases.
- Keep management and internal physician consultants informed about 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 legal records.
- Comply with applicable federal and state laws, including HIPAA, concerning 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.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
