MEDICAL CASE MANAGEMENT NURSE: RN

Medical Case Management Nurse

The Medical Case Management Nurse (MCM Nurse) provides a variety of services with respect to medical care review, cost containment, claims review, appeals and grievances, and analytical reporting. As part of our Medical Management Team, the MCM Nurse employs best practices and principles to ensure high quality and cost-effective assurance standards.

Essential duties and responsibilities include the following. Other duties may be assigned.

• Works on-site with consistent attendance.
• Conducts case reviews for appropriateness/quality of treatment and bill accordingly by group concurrently.
• Tracks and reports all hours by group and patient for current Case Management patients currently in treatment
• Develops Case Management reporting and tracking of members with trigger diagnosis history currently not in treatment and develops treatment plans to save the member and group benefit dollars.
• Maintains communication between insured, medical provider, and insurance company.
• Develop strategy, goals, & objectives for each new client.
• Provides statistical case reviews and generates utilization reports
• Examine DRG pre-certification, certification of admissions, and continued stay.
• Act as a liaison between Medical and Claims departments regarding medical review issues.
• Communicate with other departments and personnel to facilitate proper adjudication of claims.
• Review medical information from various out of state facilities for medical necessity.
• Maintain medical standards for all clients.
• Communication with hospitals, physicians, and subscribers regarding certification of hospital admissions and outpatient services.
• Meets with Management team about current processes and implementing new processes
• Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
• May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.
• Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.
• Maintains compliancy with regulation changes affecting utilization management.
• Reviews patients' records and evaluates patient progress.
• Documents review information in computer. Communicates results to the appropriate parties and enters the appropriate billing information for services.
• Responds to complaints per UR guidelines.
• Records and reports all information within scope of authority
• Performs analytical reporting from a variety of reports, client charts and other documents and participates in developing strategies for medical cost containment, maintaining quality of care and client satisfaction.

The MCM Nurse will participate in the following activities either in tandem or at the direction of the department supervisor or management team:

• Actively participate with management to develop business process analyses
• Develop recommendations for appropriate solutions.
• Validate and perform quality assurance.
• Create or revise analytical approaches to reflect current priorities and circumstances.
• Develop, analyze, and implement project plans. Mobilize project teams.
• Develop plans or proposals that include cost/benefit analysis, policy, and financial, operational, and organizational implications.
• Exercise discretion, tact, and judgment when working with internal and/or external departments.

Supervisory Responsibilities:

No supervisory responsibilities for this position.

Requirements

Knowledge, Skills, & Abilities:

• Working knowledge of ICD-10, HCPCS and CPT coding.
• Excellent communication skills, both verbally and in writing are critical.
• Knowledge of principles, practices and current trends in nursing as well as best practices in quality assurance.
• Knowledge and application of state and federal laws, statutes, and regulations; excellent analytical skills; ability to work as part of a team and be self-directed; and intermediate knowledge of Word and Excel.
• Experience in project consulting, analysis, and management.
• Communication qualifications include demonstrated verbal and written communication skills and ability to present information effectively, tailor presentations to a wide variety of audiences (including executive management), present complex concepts and recommendations clearly for management decision-making purposes.
• Ability to comprehend, interprets, and applies BRMS policies; ability to continually adjust in a dynamic environment; and ability to work as a member of a team.
• Must be able to work within core hours of operation Tuesday - Saturday 8:00 am - 5:00 pm. On-Site

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience:

Graduate from accredited school of nursing with at least two years acute clinical experience with at least one year of case management or utilization review experience.

Language Skills:

Ability to read, speaks, and writes effectively in English. Ability to interpret documents such as safety rules, memos, letters, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before customers or employees of organization. Ability to effectively address or resolve customer service issues within guidelines of the position.

Mathematical Skills:

Ability to add and subtract, multiply and divide with 10's and 100's.

Reasoning Ability:

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

Certificates, Licenses, Registrations:

Current California RN or LVN License: REQUIRED

National Medical Case Management Certification: Preferred

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit for extended periods in front of a computer. The employee is frequently required to reach with hands and arms and talk or hear. The employee is occasionally required to stand; walk and use hands to finger, handle, or feel. The employee is frequently required to lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus. This position requires the employee to work in the office.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.