Medical Case Manager

Csa Travel Protection • Pembroke Pines, FL

241d • Remote

About The Position

The Medical Case Manager is a Licensed Practical Nurse or a Registered Nurse who is accountable and capable of securing and reviewing clinical data in order to approve requests for admissions, procedures and services that meet clinical review criteria. Ensures that there is coordination and delegation of care between all providers involved. Ensure that procedures / services are not duplicated and that services being rendered fall within the industry standards of care. The Medical Case Managers responsibilities include but are not limited to: assessment of strengths and weaknesses, implementation of a treatment plan, coordination and availability of resources, familiarity with the insured policy and its' limitations and the communication and documentation with the appropriate entities that require information as per the stated policies and procedures while adhering to HIPAA and/or GDPR compliance. The Medical Case Manager (UR/UM/CM) is NOT financially incentivized for decisions that result in underutilization, adverse determinations and / or denials.

Requirements

• Prior to being employed by GMMI, Medical Case Managers need to possess at least two-year experience in the field of Managed Care or related acute care areas.
• Maintains confidentiality of all pertinent client/member (patient) information.
• Basic to moderate computer literacy required.
• Basic to moderate typing competency required.
• Strong organizational and time management skills required.
• Excellent communication skills (verbal and written).
• Effective and sound decision making and problem solving skills a must.
• Ability to work both independently and in a group setting.
• Exercises and displays the ability to interact effectively with physicians, providers, internal staff and insureds' as deemed necessary.
• Able to work in a multicultural environment and manage a diverse client / patient population is required.

Nice To Haves

• Bilingual (any language)

Responsibilities

• Performs UR/UM and Case Management duties according to company policy and procedure.
• Collects client data and conducts emergent and non-emergent clinical assessment.
• Assists in the referral of patients to most appropriate provider specialty / facility within Network.
• Monitors and screens pre-authorization requests for second medical opinion referrals and/or diagnostic testing.
• Reviews hospital admissions for medical necessity and assigns LOS in accordance with established criteria.
• Sends out appropriate communication to providers, facilities and/or client.
• Refers all cases that do not fall within pre-established criteria to the Supervisor for further evaluation.
• Assists in assuring that verbal or written denial notices are distributed out to the appropriate parties in a timely manner.
• Performs duties of the discharge planning nurse to contain LOS and assure that the insured (member/patient) is receiving services within the 6 Rights: Care, Place, Time, Provider, Price and Outcome.
• Assist with the coordination (within all phases) of a repatriation /evacuation.
• Enters and maintains all applicable information related to a case in GMMI's operating software.
• Attends and participates in all departmental meetings as scheduled.
• Evaluates and reviews treatment plan for consistency of care.
• Develops realistic treatment plan in conjunction with provider recommendations.
• Performs written and oral communication with other GMMI staff to provide case information.
• Evaluates and determines the availability of resources in conjunction with policy limits and coverage.
• Implements cost management and delivers the most effective treatment plan.
• Maintains current knowledge base with regard to medical-surgical cases, utilization management, discharge planning and continued care needs.
• Reports concerns, problems, and quality assurance issues with the correct Department Head.
• Responsible for updating the 'Tracker' system and for the timely follow up on each case that is monitored in the tracker.
• Participates in issuing non-conformance and corrective actions as per ISO policy.
• Functions as a clinical resource to non-clinical staff.

Benefits

• A diverse, inclusive, professional work environment
• Flexible work schedules
• Company match on 401(k)
• Competitive Paid Time Off policy
• Generous Employer contribution for health, dental and vision insurance
• Company paid short term and long term disability insurance
• Paid Maternity and Paternity Leave
• Tuition reimbursement
• Company paid life insurance
• Employee Assistance program
• Wellness programs
• Fun employee and company events
• Discounts on travel insurance

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED