RN Care Coordinator
Location: Phoenix Arizona
Description: Monster Worldwide is currently seeking to employ RN Care Coordinator right now, this job will be placed in Arizona. For complete informations about this job opportunity please give attention to these descriptions. SUMMARY:
Responsible for: member benefit management, redirection of services, individual out-of-network contracting for specialized services, appropriateness review, concurrent review, care management screening, transition of care assistance, new/investigational technology review, and timely discharge facilitation and follow-up. Responsible for performing care coordination processes in accordance with State, Federal, BCBSAZ and other accreditation requirements as applicable. Maintain acceptable standards of ethical practice and confidentiality. Works with FEP and Commercial members.
SPECIFIC DUTIES AND RESPONSIBILITIES
- Apply medical necessity, level of care criteria, medical coverage guidelines and benefit plan requirements when indicated to determine the appropriateness of the benefit request in light of the benefit. Perform critical in-depth analysis of medical records, computer files, medical appropriateness criteria, and the member’s Benefit Plan Booklet. Coordinate requests for services with the medical director, clinical advisor, clinical pharmacist, etc. as needed.
- Assist members and provider in selecting services within the network to minimize member financial risk and maximize the member’s healthcare benefit.
- Identify and facilitate out-of-network contracting for those services not provided or not available within the network.
- Conduct concurrent review of skilled nursing facilities, extended active rehabilitation, long term acute care facilities and other assigned individual cases to determine appropriateness and level of care determinations.
- Provide coordination of benefits and services to members needing assistance when transitioning level of care or new insurance coverage.
- Assist facilities, providers, and members to identify and use appropriate discharge services to best meet the member’s discharge needs and provide continuity of care.
- Maintain complete, accurate and legible records of precertification cases per department policy to include: Utilization Management Production and Care Management databases, letters, Medical Director review forms etc.
- Demonstrate ability to apply Plan policies and procedures effectively; identify need for intervention prior to the delivery of patient care to identify and resolve potential quality, utilization, and continuing care issues. Refer quality concerns identified through the online referral process.
- Provide ‘on-call’ coverage, as needed, to address precertification as required by the Plan.
Registered Nurse with a current, valid, Arizona license; BSN or Bachelor degree in related field preferred. Completion of at least three years of clinical practice experience or equivalent health management knowledge/experience required. Prior experience in health coaching, care coordination, disease and/or case management is desirable.
KNOWLEDGE and SKILLS
- Managed care industry and medical management principles experience
- Ability to exercise independent and sound judgment with strong problem solving skills
- Ability to evaluate, interpret and explain complex information and data
- Working knowledge of McKesson InterQual® criteria, CPT-4 and ICD-9 coding preferred
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This job starts available on: Mon, 27 Aug 2012 06:38:30 GMT