Job Description
responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members enrolled with a CareSource Management Group line of business, as well as monitoring the delivery of healthcare services in a cost effective manner.
Essential Functions:
Complete prospective, concurrent and retrospective review of acute inpatient admissions, post acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment
Coordinate care and facilitate discharge to an appropriate level of care in a timely and cost-effective manner
Refer cases to CareSource Medical Directors when clinical criterial is not met or case conference is needed/appropriate
Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards
Identify and refer quality issues to Quality Improvement
Identify and refer appropriate members for Care Management
Document, identify and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and coordination of care
Provide guidance to non-clinical medical management staff
Provide guidance to and assist with oversight of LPN medical management staff
Attend medical advisement and State Hearing meetings, as requested
Assist Team Leader with special projects or research, as requested
Perform any other job-related instructions, as requested
Skills and Requirements
Completion of an accredited registered nursing (RN) degree program is required
Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice is required
Minimum of three (3) years clinical experience is required
Med/surgical, emergency acute clinical care or home health experience is preferred
Utilization Management/Utilization Reviewexperience is preferred
Medicaid/Medicare/Commercial experience is preferred
We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal employment opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment without regard to race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or the recruiting process, please send a request to HR@insightglobal.com.
