Clinical Management Nurse career at Neighborhood Health Plan of RI in Providence

Neighborhood Health Plan of RI is in need of Clinical Management Nurse on Wed, 15 May 2013 21:45:35 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: Neighborhood Health Plan of RI is in need of Clinical Management Nurse right now, this career will be placed in Rhode Island. More complete informations about this career opportunity please read the description below. Overview:
The Clinical Management Nurse works collaboratively with the health care team to determine appropriateness of medical services, procedures and care se! tting 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 transition of care from the acute setting.

Qualifications:
Required:
Licensed RN, State of RI Computer literacy with Windows based programs · Strong organizational and documentation skills
Excellent customer service orientation Strong interpersonal skills Preferred:
3 years experience in acute care Medical/Utilization review experience Case management experience Utilization review or case management certification a plus Bilingual (English/Spanish)

Duties and Responsibilities:
Responsibilities include, but are not limited to the following:
Performs pre-certification, concurrent and retrospective review of out-patient and in-patient services, including onsite at various contracted hos! pitals and/or telephonic using established criteria, Neighborh! ood plan benefit guidelines, and clinical judgment to determine appropriateness of medical services, procedures and care setting 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.

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
Reviews requests for conditional benefits and utilizes established Neighborhood clinical guidelines to determine medical necessity. Presents to Physician Advisor for authorization decision, as necessary Identifies high-risk members and initiates appropriate referrals to case management. Alerts appropriate departments of possible primary or secondary insurance coverage. Supports the referrals to case management of complex cases through use of the case management software system 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 alte! rnative services. Effectively communicates with department and team mem! bers within an acceptable allowable time frame as directed by management. Documents cost savings that may result from medical review process (i.e. bed downgrades, change to observation status, alternative setting, etc.) Communicates with ancillary departments, such as Customer Services and Provider Engagement and Contracting, , as necessary, to meet individual needs of members and providers 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 Utilizes the case management software system 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 Takes responsibility for professional deve! lopment, supports a learning environment, and meets professional competency requirements Attends all required training sessions Is proficient in all systems as required by department 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 cannot be achieved the employee will be expected to work on site at Neighborhood. Is responsible for following all of Neighborhood’s policies and procedures including those dealing with HIPAA Security and Privacy laws at all times.. Accomplishes assignments and gets work-load based on guidance from his / her management team. Assignments are subject to change, ! dependent on departmental needs Participates in department continuous q! uality improvement activities 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 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. Other duties as assigned by Manager For more information or to apply, please visit:
http://www.nhpri.org/matriarch/MultiPiecePage.asp_Q_PageID_E_185_A_PageName_E_CareersIntroPage
Neighborhood is an EOE M/F/D/V and an E-Verify Employer.
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If you were eligible to this career, please email us your resume, with salary requirements and a resume to Neighborhood Health Plan of RI.

If you interested on this career just click on the Apply button, you will be redirected to the official website

This career starts available on: Wed, 15 May 2013 21:45:35 GMT

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