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.
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.
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.