POSITION TITLE: Clinical Management Nurse (Per Diem)       

DEPARTMENT: Medical Management

REPORTS TO: Manager of Utilization and Clinical Medical Policy   

HOURS: 37.5  

FLSA: Exempt

SALARY GRADE:12  

 

Overview: 

 

The Clinical Management Nurse works collaboratively with the health care team to determine appropriateness of medical services, procedures and care setting for Neighborhood members by reviewing and evaluating medical information and individual needs and applying established national criteria and Neighborhood plan guidelines in order to ensure quality, cost effective care, and the transition of care from the acute setting.   

           

Qualifications:  

 

Required:

- Licensed RN, State of RI

- Computer literacy with Windows based programs

- Strong organizational and documentation skills

- Excellent customer service orientation

- Strong interpersonal skills

 

Preferred:

- 3 years experience in acute care

- Medical/utilization review experience

- Case management experience

- Utilization review or case management certification a plus

- Bilingual (English/Spanish)

 

Duties and Responsibilities:

Responsibilities include, but are not limited to the following:  

 

-  Performs pre-certification, concurrent and retrospective review of out-patient and in-patient services, including onsite at various contracted hospitals and/or telephonic using established criteria, Neighborhood benefit guidelines, and clinical judgment to determine appropriateness of medical services, procedures and care setting             

- Refers and discusses complex case(s) that do not meet established criteria and guidelines with the physician advisor

- Communicates with hospital staff, including but not limited to, physicians, case managers, and rehabilitation therapists, to ensure timely discharge planning and placement in most appropriate setting

- Performs on-site visits to members while hospitalized, as needed to facilitate enrollment into a case management or transitions of care program

- Evaluates requests for outpatient services such as home care, therapies and DME and makes authorization decisions based on medical necessity, benefit coverage, and the ongoing needs of the individual patient    

- Reviews requests for conditional benefits and utilizes established Neighborhood clinical guidelines to determine medical necessity.  Presents to physician advisor for authorization decision, as necessary

- Identifies high-risk members and initiates appropriate referrals to case management, COB/TPL staff, HCCT, etc.

- Supports the referrals to case management of complex cases through use of the case management software system

- Collaborates with peers internally and externally to continually ensure member’s health care needs are being met in accordance with NeighborhoodI benefit plans, and through identification of agreed upon alternatives

- Calculates cost savings that may result from medical review process (i.e. bed downgrades, change to observation status, alternative setting, etc.)

- Communicates with ancillary departments, such as  Customer Services and Provider Services, as necessary, to meet individual needs of members and providers

- Meets department and regulatory standards for accuracy, proficiency and documentation in order to communicate decisions and plan of care in an appropriate and timely manner, and to ensure appropriate reimbursement in the claims adjudicaton system

- Utilizes the case management software system to document any outreach activities associated with member enrollment in the Transitions of Care program, including educating members on how to better self manage their condition in both an acute or chronic stage including transitioning from hospital to home

- Takes responsibility for professional development, supports a learning environment, and meets professional competency requirements

 - Participates in department continuous quality improvement activities

- Other duties as assigned by Manager

     

     For more information or to apply, please visit: http://www.nhpri.org/AboutUs/Careers.aspx

Neighborhood is an EOE M/F/D/V and an E-Verify Employer