PacificSource Health Plans

Nurse Case Manager - Utilization Management

US-OR-Bend
Job ID
2017-83a
Type
Regular Full-Time
Hiring Pay Range
$68,000 to $74,000
# of Openings
1
Status
Exempt

Overview

Provide utilization management services which promote quality, cost-effective outcomes by helping the Medicaid member populations achieve effective utilization of healthcare services. Incorporate the essential functions of professional case management concepts to enhance patients’ quality of life and maximize health plan benefits. These functions include, but are not limited to:

  • Coordination and delivery of healthcare services
  • Consideration of physical, psychological, and cultural factors
  • Assessment of the patient’s specific health plan benefits and additional medical, community, or financial resources available

Responsibilities

  1. In coordination with the Claims Department, and other departments, as applicable, develop and implement a pre and post-payment review system focused on events that generated an outlier claim.
  2. Track and manage provider claims.
  3. Act as liaison and resource for claims-related situations including representation on enterprise coding committee. Facilitate changes associated with coding updates.
  4. Collect and assess patient information pertinent to patient’s history, condition, and functional abilities in order to develop a comprehensive, individualized care plan that promotes appropriate utilization, and cost-effective care and services.
  5. Perform concurrent review of patients admitted to hospitals.  Maintain telephone contact with the hospital utilization review personnel to assure appropriateness of continued stay and level of care. Identify cases that require discharge planning, including transfer to skilled nursing facilities, rehabilitation centers and home health and/or hospice services.
  6. Review referral and preauthorization requests for appropriateness of care within clinical guidelines. Incorporate knowledge of mortality, morbidity, and established standards of practice associated with surgical procedures, pharmaceuticals, medical and behavioral health diagnoses.
  7. Identify high exposure cases, case management, behavioral health or utilization review issues, pertinent inquiries, problems, and decisions that may require review, and inform the Medical Director. Present and document pertinent information to support recommended action plan.
  8. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients.
  9. Identify catastrophic or high exposure cases and work with direct supervisor for reporting these cases.
  10. Collaborate with the leadership team, as well as other departments, to review/revise/maintain Prior Authorization Grid. 
  11. Act as back up to Special Functions Nurse.
  12. Develop standard workflow processes.

Supporting Responsibilities:

  1. Meet department and company performance and attendance expectations.
  2. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.

  3. Perform other duties as assigned.

Qualifications

Work Experience: Five years nursing experience with varied medical exposure and experience. Experience in case management, including cases that require rehabilitation, home health, and hospice treatment. Insurance industry experience and claims background preferred.

 

Education, Certificates, Licenses:  Registered nurse with current unrestricted state License. Certified professional coder preferred. Certified Case Manager (CCM) as accredited by CCMC (The Commission for Case Management Certification) preferred.

 

Knowledge: Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedures codes including ICD-10, DSM-IV, and CPT Codes, health insurance and State-mandated benefits. Thorough knowledge and understanding of claims, contractual benefits and options available outside contractual benefits. Thorough knowledge of community services, providers, vendors and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision.

 

Competencies

Our Values

  • Building Customer Loyalty
  • Building Strategic Work Relationships
  • Continuous Improvement
  • Adaptability
  • Building Trust
  • Work Standards
  • Contributing to Team Success
  • Planning and Organizing

 

 

  • We are committed to doing the right thing.
  • We are one team working toward a common goal.
  • We are each responsible for our customers' experience.
  • We practice open communication at all levels of the company to foster individual, team and company growth.
  • We actively participate in efforts to improve our many communities-internal and external.
  • We encourage creativity, innovation, continuous improvement and the pursuit of excellence.

 

 

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

 

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.  Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

 

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

 

PacificSource Health Plans is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, age.

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