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:
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.
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.