Clinical Management Nurse job at in Providence

is looking of Clinical Management Nurse on Tue, 19 Mar 2013 18:50:52 GMT. Overview: The Clinical Management Nurse works collaboratively with the health care team to determine appropriateness of medical services, procedures and care setting for Neighborhood members by reviewing and evaluating medical information and individual needs and applying established national criteria and Neighborhood plan guidelines in order to ensure quality, cost effective care, and the...

Clinical Management Nurse

Location: Providence Rhode Island

Description: is looking of Clinical Management Nurse right now, this job will be placed in Rhode Island. More complete informations about this job opportunity please give attention to these descriptions. Overview:
The Clinical Management Nurse works collaboratively with the health care team to determine appropriateness of medical services, procedures and care setting for Neighborhood mem! bers by reviewing and evaluating medical information and individual needs and applying established national criteria and Neighborhood plan guidelines in order to ensure quality, cost effective care, and the transition of care from the acute setting.

Qualifications:
Required:
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Licensed RN, State of RI

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Computer literacy with Windows based programs

• Strong organizational and documentation skills

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Excellent customer service orientation

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Strong interpersonal skills

Preferred:
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3 years experience in acute care

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Medical/Utilization review experience

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Case management experience

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Utilization review or case management certification a plus

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Bilingual (English/Spanish)

Duties and Responsibilities:
Responsibilities include, but are not limited to the following:

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Performs pre-ce! rtification, concurrent and retrospective review of out-patien! t and in-patient services, including onsite at various contracted hospitals and/or telephonic using established criteria, Neighborhood plan benefit guidelines, and clinical judgment to determine appropriateness of medical services, procedures and care setting

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Refers and discusses complex case or cases that do not meet established criteria and guidelines with the Physician Advisor

• Communicates in appropriate manner, as identified by UM department, with hospital staff, including but not limited to, Physicians, Case Managers, and Rehabilitation Therapists, to ensure timely discharge planning and placement in most appropriate setting
• Ensures that all of Neighborhood's policies relative to privacy and confidentiality are followed and that any information either obtained or disclosed is done in confidence.
• When not working within the Neighborhood facility, ensures that a voicemail recording of his / her outgoing message includes ! his/her name, name of employment, and that it is a confidential voicemail box.

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Performs on-site visits to members while hospitalized, as needed to facilitate enrollment into a Case Management or Transitions of Care program

• Evaluates requests for outpatient services such as home care, therapies and DME and makes authorization decisions based on medical necessity, benefit coverage, and the ongoing needs of the individual patient

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Reviews requests for conditional benefits and utilizes established Neighborhood clinical guidelines to determine medical necessity. Presents to Physician Advisor for authorization decision, as necessary

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Identifies high-risk members and initiates appropriate referrals to case management. Alerts appropriate departments of possible primary or secondary insurance coverage.

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Supports the referrals to case management of complex cases through use of the case management software ! system

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Collaborates with peers internally and externally! to continually ensure member's health care needs are being met in accordance with Neighborhood's benefit plans, and through identification of agreed upon alternative services.

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Effectively communicates with department and team members within an acceptable allowable time frame as directed by management.

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Documents cost savings that may result from medical review process (i.e. bed downgrades, change to observation status, alternative setting, etc.)

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Communicates with ancillary departments, such as Customer Services and Provider Engagement and Contracting, , as necessary, to meet individual needs of members and providers

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Meets department and regulatory standards for accuracy, proficiency and documentation in order to communicate decisions and plan of care in an appropriate and timely manner, and to ensure appropriate reimbursement in the Claims adjudication system

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Utilizes the case management software sys! tem to document any outreach activities associated with member enrollment in the Transitions of Care program, including educating members on how to better self manage their condition in both an acute or chronic stage including transitioning from hospital to home

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Takes responsibility for professional development, supports a learning environment, and meets professional competency requirements

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Attends all required training sessions

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Is proficient in all systems as required by department

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Ensures that he/she can accomplish all required job responsibilities and tasks from his/her home/off-site work location. He/she also is responsible for acquiring all material necessary to ensure that he/she can completely accomplish all normal work requirements. If required, the equipment used must meet Neighborhood specifications and requirements (i.e., computer equipment that will be connected to Neighborhood's LAN, etc.). I If this c! annot be achieved the employee will be expected to work on site at Neig! hborhood..

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Is responsible for following all of Neighborhood's policies and procedures including those dealing with HIPAA Security and Privacy laws at all times..

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Accomplishes assignments and gets work-load based on guidance from his / her management team. Assignments are subject to change, dependent on departmental needs

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Participates in department continuous quality improvement activities

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Attends all management-identified meetings in person. In rare circumstances, the employee may be allowed to conference in, at the discretion of the management team

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Complies with all timelines and documentation protocols. Following these guidelines is an expectation relative to remaining eligible for Facility Off-Site or Home Office telecommuting, including all hospital access requirements.

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To apply, please visit http://www.nhpri.org.

Neighborhood is an EOE M/F/D/V and an E-Verify Employe! r.

>Hospital Contract Focus Area:

• Develop and maintain relationship with hospital billing staff through regularly scheduled operational meetings and site visits
• Document and communicate professional billing and credentialing requirements for the hospitals for both internal and external parties
• Finalize single case agreements for non participating providers and others as needed
• Research and document member complaints against facilities
• Work internally to insure proper processing of inpatient, outpatient and professional hospital claims
• Understand Health Edge system in general and specifically as it relates to hospital contract term configuration; work with configuration team to ensure proper payment
• Monitors contractual language to ensure compliance by both parties and recommends solutions to concerns within existing practitioner agreements
• Requests and monitors all provider additi! ons, terminations and demographic changes in the Health Edge system
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• Educate providers and their office staff regarding Neighborhood's policies and procedures
• Provide communication link between hospital personnel and Neighborhood
• Facilitate external meetings with providers
• Identify opportunities to improve operational processes between hospitals and Neighborhood and develop strategies for improvement
• Conduct internal training sessions and act as a resource for team members
• Process and enter into Neighborhood transaction system all provider additions, terminations and demographic changes
• Create reports to assist providers
• Conduct internal training sessions and act as a resource for team members
• Primary point of contact for assigned facilities/provider sites as defined by the manager

All Focus Areas:

• Special projects as requested
• Other duties as

assigned

To apply, please visit http://www.nhpri.org

Ne! ighborhood is an EOE M/F/D/V and an E-Verify Employer.
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If you were eligible to this job, please email us your resume, with salary requirements and a resume to .

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This job starts available on: Tue, 19 Mar 2013 18:50:52 GMT

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