PacificSource Health Plans

  • Special Functions Nurse

    Job Location US-ID-Boise
    Job ID
    2018-75a
    Type
    Regular Full-Time
    Hiring Pay Range
    $65,000 to $73,900
    # of Openings
    1
    Status
    Exempt
  • Overview

    The Special Functions role is a compilation of various tasks and duties to include/but not limited to; pre, post, and focused audits, clinical component of appeals, policy preparation and review, creation of Desk Top References, compliance auditing, education, and generate quality events. To accomplish these deliverables, the Special Functions Nurse will collaborate with internal partners/departments to ensure practices align with all lines of business (LOBs): Commercial, Medicare, and Medicaid, while also meeting the needs of our members, and adhere to regulatory requirements.

     

    Responsibilities

    1. Conduct monthly audits on prior authorization and inpatient events, specific to appropriate use of clinical criteria and regulatory compliance. 
    2. Coordinate and collaborate with applicable internal and external parties, specific to audit and compliance requirements and reporting.
    3. 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 generate an outlier claim.
    4. Analyze data and track/trend patterns of regulatory non-compliance within the universes; develop training programs to address patterns of concern. 
    5. Develop and review Health Services policies and procedures and desktop references. Collaborate with other departments and/or lines of business as necessary. 
    6. Assist with quality of care issues. Summarize the event. Coordinate with Claims Department to recoup dollars identified with Never Events or Significant Adverse Events.
    7. Collaborate with the leadership team, as well as other departments, to review/revise/maintain Prior Authorization Grid. 
    8. Develop standard workflow processes.
    9. Utilize Lean methodologies for continuous improvement.  Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
    10. Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
    11. Identify high-exposure cases, case management or utilization review issues, pertinent inquiries, problems, and decisions that may require review, and inform the Medical Directors. Present and document pertinent information to support recommended action plan. Monitor high-cost cases.
    12. Track and manage provider claims related to caseload. Work with Government Claims Department to assure timely and accurate adjudication of claims.
    13. Review and audit selected provider claims referred by the Claims Departments. Determine and advise regarding the appropriateness of reimbursement for services, considering diagnosis, elective treatment, regulatory requirements, criteria, and contract provisions.
    14. Represent PacificSource Health Plans with external customers and maintain positive working relationships.
    15. Assist Medical Directors in developing and reviewing guidelines, policies and procedures for the Government Health Services Department.
    16. Work with Medical Directors to facilitate patient appeals. Prepare case presentations, as directed, for Medical Grievance Review Claims and Utilization Review Committee, Policy and Procedure Review Committee (PPRC), and/or the Membership Rights Panel (MRP).

     

    Supporting Responsibilities:

    1. Serve on designated committees, teams, and task groups, as directed.
    2. Represent the Heath Services Department, both internally and externally, as requested by Medical Director, Utilization Management Director, and Health Services Managers.
    3. Meet department and company performance and attendance expectations.
    4. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    5. Meet department and company performance and attendance expectations.
    6. Perform other duties as assigned.

    Qualifications

    Work Experience: Five years of nursing experience with varied medical exposure and experience required.  Project Management experience required.  Insurance industry and utilization review experience preferred.  

     

    Education, Certificates, Licenses: Registered nurse with current unrestricted state License. Certified Case Manager (CCM) as accredited by CCMC (The Commission for Case Management Certification) preferred. Certified Professional Coding certificate within two years of hire will be required.

     

    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 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.

     

    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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