Care Coordination Nurse I

Staff in the Population Health and Health Services area: Utilize a collaborative process to assess, plan, implement, monitor and evaluate options and services required to meet the member’s, providers’ and communities’ healthcare needs. Utilizing the disease management referral and assessment process, the disease management nurse will identify the most appropriate resources to promote quality, cost effective outcomes. Utilization Review staff are responsible for providing clinical service and/or member management. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities.

• This role does not manage people
• Necessary Contacts: In order to effectively fulfill this position the incumbent must be in contact with:
  
  All internal departments, providers, subscribers, group representatives, reinsurance carriers, Department of insurance, other insurance carriers, and healthcare vendors.

• High School Diploma or equivalent required

• 4 years of direct patient care experience required
• Managed Care or claims processing experience and knowledge of medical terminology and ICD 10 codes required
• 1 year of medical review and/or authorization experience preferred

• Prefer knowledge of insurance, reinsurance, and/or customer service operations.
   
• Ability to research and analyze cases and make appropriate quality and cost effective decisions.
   
• Must be able to communicate effectively with members, providers, pharmacy staff and fellow employees at all levels of the organization.
• Must be detail oriented, organized, and self motivated.
• Must use appropriate professional judgment and be able to make decisions and delegate work appropriately while working on multiple tasks.
• Working knowledge of related software and office equipment.
   
• Ability to comprehend Medicare guidelines and assume responsibility for decisions based on these Guidelines is required.
   
• Knowledge of coding guidelines for ICD, HCPCS and CPT preferred.
   

• Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided with graduation from an accredited vocational or technical school for Practical Nursing 180 days required
• Current, unrestricted Certified Professional in Disease Management or Health Care Management license in the state of Louisiana and/or in the required jurisdictions, or where services are provided 2 years required
• Current, unrestricted Certification in Utilization Review or Managed Care in the state of Louisiana and/or in the required jurisdictions, or where services are provided 2 years required

• Assess member’s status by collecting in-depth information about the patient’s situation and functioning to identify needs in order to develop and implement a comprehensive disease management plan that will address needs.
   
• Develop and implement a plan by determining specific objectives, goals, and actions as identified through the assessment in action oriented and time specific indicators.
   
• Implement specific interventions that will lead to accomplishing the goals established in the plan.
   
• Coordinate by organizing, integrating, and modifying the resources necessary to accomplish the goals.
   
• Monitor by gathering sufficient information from relevant sources in order to determine the effectiveness of the plan.
   
• Responsible for meeting targets for staff and unit performance to maximize program value and ensure achievement of department productivity goals.
   
• Care coordination or Utilization Management as designated by RN and/or clinical leadership.
   
• Researches and interprets contract benefits to facilitate accurate benefit administration and fulfill product-specific authorization requirements.
   
• Conducts medical necessity reviews based upon the patient's condition and/or symptoms utilizing medically-accepted review criteria/guidelines, medical delegations and/or policies to provide quality healthcare and meet regulatory requirements.
   
• Responsible for reviewing, resolving, and responding to issues regarding utilization of benefits. Works closely with internal and external customers to coordinate appropriate care for authorized services.
   
• Negotiates rate of payment when provider network deficiency exists and accurately calculates and documents care management savings to initiate care management programs, identify product enhancement opportunities, and capture returns on investments (ROI).
   
• Communicates directly with members and/or providers regarding contract requirements and collects relevant planned care information via telephone to facilitate member management.
   
• Responsible for timely management for appropriate verbal notifications and/or written materials to ensure compliance with regulatory and/or operational guidelines.
   
• Responsible for meeting targets for staff and unit performance to maximize program value and ensure achievement of department productivity goals.
   
• Serves as a technical resource to the non-clinical staff by responding to inquiries regarding the interpretation of clinical information to provide clinical support for non-clinical staff involved in the review process.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.